What is the recommended workup and treatment for acute cholecystitis?

Workup and Management of Acute Cholecystitis

Initial Diagnostic Workup

Obtain right upper quadrant ultrasound immediately as the first-line imaging study, looking specifically for gallstones, gallbladder wall thickening (>3mm), pericholecystic fluid, and sonographic Murphy's sign. 1

• Ultrasound has 81% sensitivity and 83% specificity for acute cholecystitis, with 92-95% positive predictive value when gallstones are present with sonographic Murphy's sign 1, 2
• If ultrasound is inconclusive or equivocal, proceed to hepatobiliary scintigraphy (HIDA scan), which is the gold standard with 80-90% sensitivity for cystic duct obstruction 1, 2

Check laboratory values including complete blood count (looking for leukocytosis) and inflammatory markers (CRP, ESR). 3

• Typical presentation includes right upper quadrant pain, fever, nausea, and right upper quadrant tenderness on examination 2
• Evaluate for concomitant choledocholithiasis or cholangitis with liver function tests and consider MRCP if common bile duct pathology is suspected 1, 4

Immediate Medical Management

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

Antibiotic Selection Based on Patient Risk Stratification:

For stable, immunocompetent patients with community-acquired acute cholecystitis:

• First-line: Amoxicillin/Clavulanate 2g/0.2g IV every 8 hours 5, 3, 1
• Alternatives: Ceftriaxone plus Metronidazole, or Ticarcillin/Clavulanate 5, 1

For critically ill or immunocompromised patients:

• First-line: Piperacillin/Tazobactam 4g/0.5g IV every 6 hours (or 16g/2g by continuous infusion) 5, 3, 1

For patients at risk of ESBL-producing organisms (healthcare-associated infection, recent antibiotic exposure):

• Ertapenem 1g IV every 24 hours 5, 1

Additional Supportive Care:

• NPO status with intravenous fluid resuscitation 4, 6
• Analgesics as needed for pain control 4
• Nasogastric tube only if ileus is present 6

Definitive Surgical Management

Perform early laparoscopic cholecystectomy within 72 hours of diagnosis, with acceptable extension up to 7-10 days from symptom onset. 7, 3, 1, 4

• Early laparoscopic cholecystectomy (within 7 days of hospital admission and 10 days of symptom onset) results in shorter hospital stay (approximately 4 days shorter), fewer serious adverse events, and faster return to work (9 days sooner) compared to delayed surgery 7
• Laparoscopic cholecystectomy is the first-choice surgical approach when adequate resources and surgical expertise are available 7, 3
• Early surgery (within 1-3 days) is associated with fewer composite postoperative complications (11.8% vs 34.4% for late surgery), shorter hospital stays (5.4 vs 10.0 days), and lower costs 2

Risk Factors Predicting Conversion to Open Cholecystectomy:

• Age >65 years, male gender, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery 1

Alternative Management for High-Risk Patients

For patients unfit for surgery (critically ill, multiple comorbidities, or failing medical management after 3-5 days), perform percutaneous cholecystostomy as a temporizing measure. 7, 3

• Cholecystostomy is safe and effective for critically ill patients unfit for surgery 7
• However, percutaneous cholecystostomy is associated with higher postprocedural complications (65%) compared to laparoscopic cholecystectomy (12%) 2
• This serves as a "bridge" until definitive surgery can be performed when the patient stabilizes 5

Duration of Antibiotic Therapy

For uncomplicated cholecystitis with complete source control (successful cholecystectomy), discontinue antibiotics within 24 hours post-operatively—no postoperative antibiotics are necessary. 5, 1, 8

For complicated cholecystitis with adequate source control:

• Immunocompetent, non-critically ill patients: Maximum 4 days of antibiotics 5, 1, 8
• Immunocompromised or critically ill patients: Up to 7 days of antibiotics 5, 1

Special Considerations and Pitfalls

If moderate/severe acute cholangitis is present, ERCP is the treatment of choice for biliary decompression before cholecystectomy. 7, 1

For gallbladder perforation, early diagnosis and immediate surgical intervention substantially decrease morbidity and mortality. 7

In pregnant patients, early laparoscopic cholecystectomy is associated with lower maternal-fetal complications (1.6% vs 18.4% for delayed management) and is recommended during all trimesters. 2

In elderly patients (>65 years), laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared to nonoperative management (29.3%). 2

Common Pitfalls to Avoid:

• Do not delay surgery beyond 7-10 days from symptom onset, as this increases complications and hospital stay 7
• Do not continue broad-spectrum antibiotics after adequate source control, as this promotes resistance 3
• Conservative management alone (without surgery) results in 30% recurrence of complications and 60% ultimately requiring cholecystectomy 7, 5
• Anaerobic coverage is not required unless biliary-enteric anastomosis is present 5
• Enterococcal coverage is only needed for healthcare-associated infections 5