What is the recommended treatment for chronic cholecystitis?

Treatment of Chronic Cholecystitis

Laparoscopic cholecystectomy is the gold standard and definitive treatment for chronic cholecystitis. 1, 2

Diagnosis

• Chronic cholecystitis is diagnosed based on clinical features including recurrent right upper quadrant pain (often postprandial), with or without fever and leukocytosis 2
• Ultrasound is the primary imaging modality, showing gallstones, possibly thickened gallbladder wall, and other signs of inflammation 1

Treatment Algorithm

First-line Treatment

• Laparoscopic cholecystectomy is the treatment of choice for chronic cholecystitis 1, 3
• Early laparoscopic cholecystectomy (within 7 days of symptom onset) is recommended over delayed cholecystectomy 2
• Early intervention is associated with:
  • Shorter recovery time and hospitalization 2
  • Lower hospital costs 2
  • Fewer work days lost 2
  • Greater patient satisfaction 2
  • Reduced risk of recurrent gallstone-related complications 2

Perioperative Management

• For uncomplicated cholecystitis with complete source control, no postoperative antimicrobial therapy is necessary 1, 2
• Initial management before surgery may include:
  • Intravenous fluids for hydration 2
  • Appropriate analgesia 4
  • Antibiotics if signs of infection are present 4

Alternative Approaches

• Open cholecystectomy remains a feasible option, particularly in low-income countries or settings with resource limitations 1
• Cholecystostomy (gallbladder drainage) is recommended for patients who are:
  • Critically ill 1
  • Have multiple comorbidities 1
  • Are unfit for surgery 2

Special Considerations

Risk Factors for Conversion to Open Surgery

• Age >65 years 1, 2
• Male gender 1, 2
• Acute inflammation 1
• Thickened gallbladder wall 1, 2
• Diabetes mellitus 1, 2
• Previous upper abdominal surgery 1, 2

Complications and Management

• Early diagnosis of gallbladder perforation and immediate surgical intervention may substantially decrease morbidity and mortality 1, 5
• Long-term follow-up shows that about 30% of conservatively treated patients develop recurrent gallstone-related complications and 60% eventually undergo cholecystectomy 2

Emerging Techniques

• Endoscopic gallbladder drainage techniques are being developed as alternatives for patients who are poor surgical candidates 6
• These include:
  • Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) 6
  • Endoscopic trans-papillary gallbladder drainage (ETGBD) 6

Clinical Pearls

• The overall mortality rate for cholecystectomy across all age groups is approximately 0.5%, with slight increases in elderly patients and those with acute inflammation 3
• Patients with symptoms typical of biliary colic but normal gallbladder sonography may still benefit from laparoscopic cholecystectomy in the majority of cases 7
• Conversion from laparoscopic to open surgery should not be considered a failure but rather a valid option when necessary for patient safety 2