What is the recommended management for acute cholecystitis?

Management of Acute Cholecystitis

Early laparoscopic cholecystectomy within 7 days of symptom onset is the definitive treatment of choice for acute cholecystitis, combined with prompt initiation of empiric antibiotic therapy based on disease severity. 1, 2

Immediate Initial Management

Diagnostic Confirmation

• Ultrasound is the first-line imaging modality, demonstrating gallstones, gallbladder wall thickening (>5mm), pericholecystic fluid, and ultrasonographic Murphy's sign with 92-95% positive predictive value when combined with stones. 1, 3
• Hepatobiliary scintigraphy (HIDA scan) serves as the gold standard when ultrasound is inconclusive, with 80-90% sensitivity for cystic duct obstruction. 1

Supportive Care

• Initiate intravenous fluid resuscitation immediately. 4
• Keep patient NPO (nothing by mouth). 4
• Administer analgesics that do not mask clinical signs needed for monitoring. 5
• Place nasogastric tube only if ileus is present. 4

Antibiotic Therapy

For Stable, Immunocompetent Patients (Community-Acquired)

• First-line: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours. 2, 3
• Alternative: Ceftriaxone plus metronidazole. 2
• Alternative: Ticarcillin/clavulanate. 2

For Critically Ill or Immunocompromised Patients

• First-line: Piperacillin/tazobactam 4g/0.5g IV every 6 hours or 16g/2g by continuous infusion. 2, 3

For Patients at Risk of ESBL-Producing Organisms

• Ertapenem 1g IV every 24 hours. 2

Special Antibiotic Considerations

• Anaerobic coverage is NOT required unless biliary-enteric anastomosis is present. 2
• Enterococcal coverage is only needed for healthcare-associated infections. 2
• MRSA coverage (vancomycin) should only be added for healthcare-associated infections in colonized patients or those with prior treatment failure. 2
• There is no evidence that antibiotics with enhanced biliary excretion improve outcomes. 1

Definitive Surgical Management

Timing of Surgery

• Early laparoscopic cholecystectomy (ELC) within 72 hours of diagnosis, with possible extension up to 7-10 days from symptom onset, is superior to delayed surgery. 1, 2, 6
• ELC results in shorter hospital stays, faster recovery, lower costs, fewer work days lost, and greater patient satisfaction compared to delayed cholecystectomy. 1, 7
• Early surgery (within 1-3 days) is associated with fewer composite postoperative complications (11.8% vs 34.4% for late surgery) and shorter length of stay (5.4 vs 10.0 days). 7

Surgical Approach

• Laparoscopic cholecystectomy is the first-choice surgical approach when adequate resources and surgical expertise are available. 1, 5
• Risk factors predicting conversion to open cholecystectomy include: age >65 years, male gender, acute cholecystitis, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery. 1
• Open cholecystectomy remains feasible in resource-limited settings or when laparoscopic approach is not available. 1

Duration of Antibiotic Therapy Post-Surgery

• For uncomplicated cholecystitis with complete source control: NO postoperative antibiotics are necessary. 1, 2, 3, 8
• For complicated cholecystitis with adequate source control in immunocompetent, non-critically ill patients: 4 days maximum. 2, 8
• For immunocompromised or critically ill patients: up to 7 days. 2
• Antimicrobial therapy should be discontinued within 24 hours after cholecystectomy unless there is evidence of infection outside the gallbladder wall. 2

Alternative Management for High-Risk Patients

Percutaneous Cholecystostomy

• Reserved for critically ill patients with multiple comorbidities who are unfit for surgery. 1, 4
• Serves as a safe and effective temporizing "bridge to surgery" measure. 2, 4
• Important caveat: Percutaneous cholecystostomy is associated with higher postprocedural complication rates (65%) compared to laparoscopic cholecystectomy (12%). 7

Conservative Management Alone

• Conservative management with antibiotics alone should only be considered as a temporary measure for patients with prohibitive surgical risk, NOT as definitive treatment. 2, 3, 9
• Critical limitation: 20-30% develop recurrent gallstone-related complications, and 60% ultimately require cholecystectomy. 2, 9
• Conservative treatment should be viewed as a bridge to surgery rather than a definitive solution due to frequent recurrence. 9

Special Populations

Pregnant Patients

• Early laparoscopic cholecystectomy is recommended during all trimesters, as it is associated with lower maternal-fetal complications (1.6% vs 18.4% for delayed management). 7

Elderly Patients (>65 years)

• Laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared to nonoperative management (29.3%). 7
• Elderly patients with uncomplicated cholecystitis do not require postoperative antibiotics when source control is achieved. 3

Patients with Concomitant Choledocholithiasis/Cholangitis

• MRCP should be performed to evaluate the common bile duct. 3
• ERCP is the treatment of choice for biliary decompression in moderate/severe acute cholangitis. 1

Common Pitfalls to Avoid

• Do not delay surgery beyond 7-10 days from symptom onset in operable patients, as this increases complications and recurrence rates. 1, 6
• Do not continue antibiotics postoperatively in uncomplicated cases after successful cholecystectomy, as this provides no benefit. 2, 8
• Do not rely on conservative management as definitive treatment except in truly inoperable patients, as 76% eventually require surgery. 9
• Do not add unnecessary broad-spectrum coverage (anaerobes, enterococci, MRSA) in community-acquired cases without specific risk factors. 2
• Obtain microbiological cultures in complicated cases to guide targeted therapy. 2, 3