What is the treatment for significant gallbladder distension?

Treatment of Significant Gallbladder Distension

Laparoscopic cholecystectomy is the definitive first-line treatment for significant gallbladder distension, with surgery recommended as soon as the patient is medically stable and sepsis is controlled. 1

Initial Management and Stabilization

Medical Management First

• Initiate broad-spectrum antibiotics immediately (within 1 hour if septic, within 6 hours for less severe cases) using piperacillin/tazobactam, meropenem, or 4th-generation cephalosporins 1
• Correct coagulopathies and provide hemodynamic support with IV fluids and vasopressors if needed 1
• Obtain contrast-enhanced CT scan to assess for complications including gallbladder perforation, gangrene, or volvulus 2

Biliary Decompression for Severe Cases

• If the patient has biliary sepsis or acute cholangitis with distension, endoscopic biliary drainage with plastic stent placement is the preferred initial intervention before definitive cholecystectomy 1
• Percutaneous cholecystostomy may be considered in critically ill patients who cannot tolerate surgery, though this is a temporizing measure only 1

Definitive Surgical Treatment

Laparoscopic Cholecystectomy

• Laparoscopic cholecystectomy should be performed as the definitive treatment once the patient is stabilized, with low complication rates and shortened hospital stays compared to open surgery 1, 3
• The Critical View of Safety must be achieved by clearing the hepatocystic triangle of all fat and fibrous tissue, clearing the lower third of the gallbladder from the liver bed, and visualizing only two structures (cystic duct and cystic artery) entering the gallbladder 3

When Laparoscopic Approach is Difficult

• If anatomic identification is difficult due to severe distension, inflammation, or adhesions, perform subtotal cholecystectomy rather than risking bile duct injury 1, 3, 4
• Convert to open cholecystectomy if the Critical View of Safety cannot be achieved rather than persisting with dangerous dissection 3
• Intraoperative cholangiography or laparoscopic ultrasound should be performed if there is unclear anatomy or suspicion of bile duct injury 1, 3

Contraindications to Immediate Surgery

Avoid laparoscopic cholecystectomy in the following situations: 1, 3

• Septic shock requiring ongoing vasopressor support
• Absolute anesthesiology contraindications
• Uncorrected severe coagulopathy (INR >2.0 or platelets <60K) 1

In these cases, temporize with percutaneous cholecystostomy or endoscopic biliary drainage, then perform delayed cholecystectomy once the patient is optimized 1

Special Considerations

Concurrent Common Bile Duct Stones

• If high-risk features for choledocholithiasis are present (CBD stone on imaging, elevated bilirubin >4 mg/dL), perform preoperative ERCP with sphincterotomy and stone extraction 1
• Alternatively, perform intraoperative cholangiography or laparoscopic ultrasound to detect CBD stones during cholecystectomy 1

Gallbladder Volvulus

• If CT demonstrates a "beak sign" or "swirl sign" with abnormal gallbladder positioning, this indicates gallbladder volvulus requiring urgent surgical intervention 2
• Gangrenous changes may develop rapidly, making early recognition and surgery critical 2

Critical Pitfalls to Avoid

• Never persist with difficult dissection when anatomy is unclear—this is the leading cause of bile duct injury 3, 4
• Do not delay antibiotics—they must be started within 1 hour for septic patients 1
• Avoid diagnostic ERCP without therapeutic intent in stable patients, as it carries 1-2% complication rates including pancreatitis 1
• Do not assume distension alone is benign—it may indicate obstruction, volvulus, or impending perforation requiring urgent intervention 2, 5