What is the recommended evaluation and management for acute cholecystitis?

Acute Cholecystitis Evaluation and Management

Diagnostic Evaluation

Ultrasound is the investigation of choice for suspected acute cholecystitis, with diagnosis confirmed by the presence of gallstones plus either a positive ultrasonographic Murphy's sign (92% positive predictive value) or gallbladder wall thickening ≥5mm (95% positive predictive value). 1

Clinical Presentation

• Right upper quadrant pain, fever, and leukocytosis are the cardinal clinical features 1, 2
• Physical examination should specifically assess for Murphy's sign 1

Imaging Findings on Ultrasound

• Gallstones (detected in ~98% of cases) 1
• Pericholecystic fluid 1, 2
• Distended gallbladder 1, 2
• Edematous gallbladder wall (≥5mm thickening) 1, 2
• Ultrasonographic Murphy's sign (direct tenderness when probe pushed against gallbladder) 1

Alternative Imaging

• Hepatobiliary scintigraphy (HIDA scan) can be used when ultrasound is equivocal, showing 80-90% sensitivity for acute cholecystitis based on absence of gallbladder filling within 60 minutes 1

Management Algorithm

Early laparoscopic cholecystectomy within 7 days of hospital admission and within 10 days from symptom onset is the definitive treatment, resulting in shorter recovery time, reduced hospital costs, fewer work days lost, and lower rates of recurrent biliary complications compared to delayed surgery. 2, 3

Immediate Pre-Operative Management

• Intravenous fluid resuscitation 4
• Nothing by mouth 4
• Antimicrobial therapy targeting Enterobacteriaceae 3
• Analgesia (opioids for severe pain, with multimodal approach including acetaminophen 1g every 6 hours and NSAIDs) 5
• Nasogastric tube only if ileus is present 4

Surgical Timing

• Optimal window: within 72 hours of diagnosis, with acceptable extension up to 7-10 days from symptom onset 6
• Early laparoscopic cholecystectomy results in approximately 4 days shorter total hospital stay and 9 days sooner return to work compared to delayed approach 3
• Laparoscopic approach is preferred over open cholecystectomy due to shorter hospital stay, less pain, and earlier return to productivity 4

Antibiotic Duration

• For uncomplicated acute cholecystitis with complete source control at surgery, no postoperative antimicrobial therapy is necessary 1, 2, 3
• Complicated cases require short-course postoperative antibiotics 3
• High-risk patients (Class C) require postoperative antibiotic therapy 3

Special Populations and Alternative Approaches

High-Risk Surgical Candidates

Immediate laparoscopic cholecystectomy is superior to percutaneous transhepatic gallbladder drainage (PTGBD) even in high-risk patients, with the CHOCOLATE trial demonstrating only 5% complications versus 53% with PTGBD in critically ill patients. 2, 3

Patients Unfit for Surgery

• Gallbladder drainage (cholecystostomy) via percutaneous catheter placement under local anesthesia is recommended 2, 4
• Percutaneous cholecystostomy converts a septic patient into a non-septic patient by decompressing infected bile or pus 2
• Endoscopic transpapillary drainage is an alternative option 4

Conservative Management

• Conservative management with fluids, analgesia, and antibiotics may be considered for mildly symptomatic acute cholecystitis 2
• However, long-term outcomes are poor: approximately 30% develop recurrent gallstone-related complications during 14-year follow-up, and 60% eventually undergo cholecystectomy 2, 3
• If surgery is delayed, it should be performed at least 6 weeks after clinical presentation 6

Risk Factors for Conversion to Open Surgery

• Age >65 years 2
• Male gender 2
• Thickened gallbladder wall 2
• Diabetes mellitus 2
• Previous upper abdominal surgery 2
• Conversion to open surgery is not a failure but a valid option when necessary for patient safety 2

Common Pitfalls to Avoid

• Do not delay early cholecystectomy beyond 7-10 days from symptom onset, as this increases conversion rates and complications 2, 3
• Do not routinely use antibiotics postoperatively in uncomplicated cases, as source control is complete with cholecystectomy 1, 2
• Do not assume PTGBD is safer than surgery in high-risk patients—immediate laparoscopic cholecystectomy has superior outcomes even in critically ill patients 2, 3
• Do not discharge patients for delayed cholecystectomy without counseling about the 30% risk of recurrent complications 2, 3