What is the treatment for chronic cholecystitis and cholelithiasis with cholesterolosis?

Treatment of Chronic Cholecystitis and Cholelithiasis with Cholesterolosis

Laparoscopic cholecystectomy performed within 7-10 days of symptom onset is the definitive treatment for chronic cholecystitis with cholelithiasis, regardless of the presence of cholesterolosis. 1

Surgical Management: The Gold Standard

Early laparoscopic cholecystectomy is superior to delayed surgery and should be performed within 7-10 days of symptom onset for uncomplicated cases. 1 This approach results in:

• Shorter recovery time and hospitalization compared to delayed cholecystectomy 1
• Prevention of future biliary pain, complications, gallstone recurrence, and gallbladder cancer 1
• Success rates of 95% with complication rates of 5-18% 1
• No limitation by stone size or composition, unlike nonsurgical therapies 1

Antibiotic Prophylaxis

• Single-dose prophylaxis only if early intervention is performed 1
• No postoperative antibiotics are necessary if source control is complete in uncomplicated cases 1

For Complicated Cholecystitis

If complications develop (gangrenous gallbladder, perforation, abscess), the approach changes: 1

• Laparoscopic cholecystectomy remains first-line, with open cholecystectomy as alternative 1
• Antibiotic therapy for 4 days in immunocompetent, non-critically ill patients with adequate source control 1
• Antibiotic therapy up to 7 days in immunocompromised or critically ill patients based on clinical response 1

Antibiotic Selection for Complicated Cases:

For non-critically ill, immunocompetent patients: 1

• Amoxicillin/Clavulanate 2g/0.2g q8h
• If beta-lactam allergy: Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose then 50 mg q12h

For critically ill or immunocompromised patients: 1

• Piperacillin/tazobactam 6 g/0.75 g loading dose then 4 g/0.5 g q6h or 16 g/2 g by continuous infusion
• If beta-lactam allergy: Eravacycline 1 mg/kg q12h

For inadequate/delayed source control or high risk of ESBL-producing organisms: 1

• Ertapenem 1 g q24h, or
• Eravacycline 1 mg/kg q12h

Special Consideration: Cholesterolosis

Cholesterolosis does not alter the surgical indication or approach. 2, 3 Important points about cholesterolosis:

• Found in 13.4% of cholecystectomy specimens, more common in women (14.2% vs 10.2% in men) 3
• Patients with cholesterolosis show excellent symptomatic improvement after cholecystectomy (95% improvement rate vs 58% in chronic cholecystitis alone) 2
• Cholesterolosis has a strong negative association with gallbladder cancer (9.2 times less likely to have cancer) 3
• Gallstones are less frequent in cholesterolosis cases (59.4% vs 75% in non-cholesterolosis cases) 4

Nonsurgical Options: Limited Role

Nonsurgical therapies have significant limitations and are not recommended as primary treatment: 1, 5

Oral Bile Acid Therapy (Ursodeoxycholic Acid)

• Only suitable for cholesterol stones <15 mm diameter 1
• Requires 6-24 months of daily therapy 1, 5
• Complete dissolution achieved in only 30% of unselected patients 5
• Stone recurrence occurs in 30-50% within 2-5 years after dissolution 5
• Does not prevent gallbladder cancer 1
• Accounts for only 20% of potential cholecystectomy candidates 1

Alternative for High-Risk Surgical Patients

Cholecystostomy may be considered for: 1

• Patients with multiple comorbidities unfit for surgery 1
• Critically ill patients who fail to improve after antibiotic therapy 1
• Important caveat: Cholecystostomy is inferior to cholecystectomy in terms of major complications for critically ill patients 1

Diagnostic Workup

Ultrasound is the investigation of choice for suspected cholecystitis: 1

• 90-95% sensitive for gallstones 6
• Shows pericholecystic fluid, distended gallbladder, edematous wall, and impacted stones 1
• Murphy's sign can be elicited on ultrasound examination 1

MRCP should be obtained if common bile duct stones are suspected 1

Common Pitfalls to Avoid

• Do not delay surgery beyond 10 days in symptomatic patients, as this increases conversion rates to open cholecystectomy and complications 1
• Do not pursue nonsurgical dissolution therapy as primary treatment—it has high failure and recurrence rates 1, 5
• Do not continue antibiotic therapy beyond 7 days without diagnostic re-evaluation if signs of infection persist 1
• Do not assume cholesterolosis requires different management—surgical approach remains identical 2, 3