From the Guidelines
Perforated cholecystitis requires immediate surgical intervention with laparoscopic or open cholecystectomy as the definitive treatment. Before surgery, patients should be stabilized with IV fluids, broad-spectrum antibiotics (such as piperacillin-tazobactam 3.375g IV q6h, or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV q8h), and adequate pain control with opioid analgesics 1.
Key Considerations
- Percutaneous cholecystostomy may be considered as a temporizing measure in critically ill patients who cannot tolerate immediate surgery 1.
- Postoperatively, antibiotics should be continued for at least 4-7 days depending on clinical response, with longer courses needed if there is evidence of ongoing infection.
- Drainage of any associated abscess is essential, and patients require close monitoring for complications such as sepsis, peritonitis, or multi-organ dysfunction.
- The high mortality rate associated with perforated cholecystitis (up to 30%) due to the risk of biliary peritonitis and septic shock, makes rapid diagnosis with imaging (ultrasound or CT scan) and prompt treatment crucial 1.
Treatment Approach
- Early laparoscopic cholecystectomy is superior to percutaneous transhepatic gallbladder drainage (PTGBD) in high-risk patients with acute calculus cholecystitis 1.
- The timing of laparoscopic cholecystectomy is crucial, with most trials performing ELC within 10 days of onset of symptoms.
- Referral to centers with high surgical expertise should be considered if adequate surgical expertise is not available.
Important Considerations
- The underlying pathophysiology involves gallstone obstruction leading to increased pressure, inflammation, ischemia, and eventual perforation of the gallbladder wall, allowing bile and bacteria to leak into the peritoneal cavity.
- The choice between laparoscopic and open cholecystectomy depends on the patient's condition, surgical expertise, and available resources.
- Laparoscopic cholecystectomy is the preferred approach for patients with acute cholecystitis who are fit for surgery 1.
From the Research
Treatment for Perforated Cholecystitis
The treatment for perforated cholecystitis, a severe form of gallbladder inflammation, can vary depending on the severity of the condition and the patient's overall health.
- Early diagnosis and emergency surgical treatment are crucial for perforated cholecystitis, as it can lead to severe complications such as sepsis and multiple organ failure 2.
- According to the Tokyo Guidelines, the current standard of treatment for acute cholecystitis, including perforated cholecystitis, involves surgical intervention, with laparoscopic cholecystectomy being the preferred procedure for mild to moderate cases 3.
- For patients with severe local inflammation, such as gangrenous or purulent cholecystitis, early gallbladder drainage or open cholecystectomy may be indicated 4.
- In high-risk patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, serving as a bridge to cholecystectomy 5.
- The optimal treatment modality should be individualized based on the patient's clinical conditions and available expertise, and patients with elevated surgical risk should be preferably treated in tertiary hospitals with access to surgical, radiological, and endoscopic expertise and resources 5.
Surgical Treatment
Surgical treatment for perforated cholecystitis may involve:
- Laparoscopic cholecystectomy, which is the preferred procedure for mild to moderate cases 4, 3.
- Open cholecystectomy, which may be indicated for patients with severe local inflammation or those who are not suitable for laparoscopic surgery 4, 2.
- Percutaneous cholecystostomy, which involves the placement of a catheter to drain the gallbladder, and may be used as a temporary measure to stabilize the patient before surgery 5.
Non-Surgical Treatment
Non-surgical treatment for perforated cholecystitis may involve:
- Antibiotic therapy, which may be used to manage the infection and prevent further complications 3.
- Analgesics and anti-inflammatory medications, which may be used to manage pain and inflammation 3.
- Supportive care, such as fluid replacement and nutritional support, which may be necessary to stabilize the patient and manage any underlying conditions 3.