What is the management of acalculous cholecystitis?

Management of Acalculous Cholecystitis

Early laparoscopic cholecystectomy within 7-10 days of symptom onset is the definitive treatment for acalculous cholecystitis, even in high-risk patients, as it results in significantly fewer complications (5% vs 53%) and better outcomes compared to percutaneous drainage. 1, 2

Initial Assessment and Diagnosis

Diagnostic Workup:

• Obtain ultrasound immediately looking for gallbladder wall thickening (>5mm), pericholecystic fluid, distended gallbladder, and sonographic Murphy's sign 1, 3
• Check white blood cell count and inflammatory markers 3
• Consider hepatobiliary scintigraphy if ultrasound is equivocal—absence of gallbladder filling within 60 minutes indicates cystic duct obstruction with 80-90% sensitivity 1
• Maintain high index of suspicion in critically ill patients, especially those with trauma, burns, sepsis, prolonged fasting, or on total parenteral nutrition 4

Antibiotic Therapy

Start empirical antibiotics immediately upon diagnosis, before any surgical intervention. 3

For stable, immunocompetent patients with uncomplicated disease:

• First-line: Amoxicillin/Clavulanate 2g/0.2g IV every 8 hours 3, 2
• Alternatives: Ceftriaxone plus Metronidazole, or Ticarcillin/Clavulanate 3

For critically ill, immunocompromised, or complicated cases:

• First-line: Piperacillin/Tazobactam 4g/0.5g IV every 6 hours (or 16g/2g continuous infusion) 3, 2, 5
• Alternatives for septic shock: Meropenem 1g every 6 hours by extended infusion, Doripenem 500mg every 8 hours, or Imipenem/Cilastatin 500mg every 6 hours 5
• For beta-lactam allergy: Eravacycline 1mg/kg every 12 hours 5
• For ESBL risk: Ertapenem 1g every 24 hours or Eravacycline 5

Antibiotics with optimal biliary penetration include: Piperacillin/Tazobactam, Tigecycline, Amoxicillin/Clavulanate, Ciprofloxacin, Ampicillin/Sulbactam, Ceftriaxone, and Levofloxacin 1, 2

Surgical Management Algorithm

For patients fit for surgery:

• Perform early laparoscopic cholecystectomy within 7-10 days of symptom onset 1, 3, 2
• This approach results in shorter hospital stays, faster recovery, and fewer readmissions compared to delayed surgery 1, 2
• Even high-risk patients (APACHE score 7-14) benefit from early surgery over drainage procedures 1
• Laparoscopic approach is safe and effective as first choice where adequate resources and skill are available 1

For patients not suitable for surgery:

• Perform percutaneous transhepatic gallbladder drainage (PTGBD) if patient fails conservative management after 24-48 hours or presents with sepsis from gallbladder empyema 1, 2
• PTGBD has 85.6% success rate with only 0.36% procedure-related mortality 1, 2
• PTGBD effectively converts septic patients to non-septic by decompressing infected bile 1, 2
• Consider endoscopic transpapillary gallbladder drainage (ETGBD) or EUS-guided transmural drainage as alternatives to PTGBD in high-volume centers with skilled endoscopists 1

Predictors of conservative management failure at 24 hours:

• Age >70 years, tachycardia (>100 bpm), distended gallbladder (>5cm diameter) 2

Predictors of conservative management failure at 48 hours:

• WBC >15,000 cells/mm³, persistent fever, age >70 years 2

Antibiotic Duration

After early cholecystectomy with adequate source control:

• Single-dose prophylaxis only; discontinue antibiotics within 24 hours postoperatively if no infection outside gallbladder wall 1, 3, 2

For complicated disease with adequate source control:

• Immunocompetent patients: 4 days of therapy 2, 5
• Immunocompromised patients (including diabetics): up to 7 days based on clinical condition and inflammatory markers 2, 5

For patients managed with PTGBD:

• No specific antibiotic regimen required alongside drainage; follow general principles above 1

Delayed Cholecystectomy Considerations

After PTGBD, offer delayed laparoscopic cholecystectomy once perioperative risks are reduced to decrease readmission for recurrent disease 1

• 40% of patients undergo delayed cholecystectomy after PTGBD 1, 2
• Patients who do not undergo delayed cholecystectomy have 49% one-year readmission rate 1, 2
• Only 7% recurrence rate in patients managed definitively with PTGBD alone without subsequent surgery 6

Special Populations

Critically ill patients:

• AAC occurs most commonly in trauma, surgery, shock, burns, sepsis, and prolonged fasting settings 4
• Early diagnosis requires high index of suspicion as symptoms are often nonspecific 4
• Mortality is high (21-30%) but improves with early intervention 6, 7, 4

Pediatric patients:

• Conservative management with antibiotics and close radiological monitoring may be appropriate for selected critically ill children with underlying infection 7
• Surgery carries risks in this population; non-operative intervention can be safe and effective 7

Diabetic patients:

• Consider immunocompromised; require broader antimicrobial coverage with Piperacillin/Tazobactam as first-line 5
• Higher risk for gangrenous cholecystitis and perforation 5
• Require up to 7 days of antibiotic therapy even with adequate source control 5

Critical Pitfalls to Avoid

Do NOT delay surgery in surgical candidates based solely on age or comorbidities—evidence demonstrates early laparoscopic cholecystectomy is safe even in high-risk patients 1, 2

Do NOT overuse drainage procedures in patients who could safely undergo surgery—this leads to higher mortality, longer hospital stays, and more readmissions 2

Do NOT discontinue antibiotics prematurely in patients with biliary sepsis—biliary origin of peritonitis is a mortality risk factor in septic shock 2

Do NOT rely on antibiotics alone for definitive management—systematic review shows antibiotics are not indicated for conservative management of cholecystitis 8