What is the diagnosis and treatment for Cholecystitis (inflammation of the gallbladder)?

From the Guidelines

Early laparoscopic cholecystectomy is the recommended treatment for acute cholecystitis, as it offers a safe and effective approach with shorter recovery time and hospitalization compared to delayed cholecystectomies. This approach is supported by the most recent guidelines, including the 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis 1. The management of acute cholecystitis involves a combination of hospitalization, bowel rest, IV fluids, and antibiotics such as piperacillin-tazobactam, ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole for 4-7 days. Pain management with opioids like morphine or hydromorphone is also recommended.

Key Considerations

• The diagnosis of acute cholecystitis is made on the basis of clinical features such as right upper quadrant pain, fever, and leukocytosis, and is supported by findings from relevant imaging studies, with ultrasound being the investigation of choice 1.
• Early cholecystectomy is a safe treatment for acute cholecystitis and generally results in shorter recovery time and hospitalization compared to delayed cholecystectomies 1.
• For patients who cannot undergo surgery, percutaneous cholecystostomy tube placement may be considered, and endoscopic ultrasound–guided gallbladder drainage (EUS-GBD) is a viable option for high-risk surgical patients 1.
• The Italian Council for the Optimization of Antimicrobial Use recommends early laparoscopic cholecystectomy for uncomplicated cholecystitis, with one-shot prophylaxis if early intervention, and no post-operative antibiotics 1.

Treatment Approach

• Laparoscopic cholecystectomy is the preferred treatment for acute cholecystitis, with open cholecystectomy as an alternative, and antibiotic therapy for 4 days in immunocompetent and non-critically ill patients if source control is adequate 1.
• Cholecystostomy may be an option for acute cholecystitis in patients with multiple comorbidities and unfit for surgery, with antibiotic therapy for 4 days, although it is inferior to cholecystectomy in terms of major complications for critically ill patients 1.

Prevention and Management

• Prevention strategies include maintaining a healthy weight, eating regular meals, and following a low-fat diet.
• Prompt treatment is essential to prevent complications like gangrene, perforation, or sepsis.
• After cholecystectomy, most patients can resume normal activities within 1-2 weeks and adapt well to life without a gallbladder, though some may experience temporary digestive changes.

From the Research

Definition and Diagnosis of Cholecystitis

• Acute cholecystitis (AC) is a relatively frequent disease that can lead to serious complications, generally associated with the presence of gallstones 2.
• The typical presentation of acute cholecystitis consists of acute right upper quadrant pain, fever, and nausea that may be associated with eating and physical examination findings of right upper quadrant tenderness 3.
• Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis 3.
• When an ultrasound result does not provide a definitive diagnosis, hepatobiliary scintigraphy is the gold standard diagnostic test 3.

Treatment of Cholecystitis

• Early laparoscopic cholecystectomy (ELC) is considered the best treatment for AC, with the optimal timeframe to perform ELC being within 72 h from diagnosis, with a possible extension of up to 7-10 days from symptom onset 2.
• In patients who are not eligible for ELC, it is suggested to delay surgery at least 6 weeks after the clinical presentation 2.
• Critically ill patients, who are unfit for surgery, may require rescue treatments, such as percutaneous or endoscopic gallbladder drainage (GBD) 2, 4.
• Antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis 5.

Special Populations and Treatment Approaches

• A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients 2.
• In pregnant women, early laparoscopic cholecystectomy is associated with a lower risk of maternal-fetal complications and is recommended during all trimesters 3.
• In people older than 65 years of age, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up compared with nonoperative management 3.
• In patients with acalculous acute cholecystitis, percutaneous cholecystostomy tube should be reserved for patients who are severely ill at the time of diagnosis; all others should undergo a laparoscopic cholecystectomy 3.