What is the treatment for acute cholecystitis?

Treatment of Acute Cholecystitis

Early laparoscopic cholecystectomy within 7 days of hospital admission (and within 10 days of symptom onset) is the definitive treatment for acute cholecystitis and should be performed as soon as the patient is medically optimized. 1

Initial Medical Management (Pre-operative Stabilization)

Before proceeding to surgery, stabilize the patient with:

• Intravenous fluid resuscitation to correct dehydration and maintain hemodynamic stability 1, 2
• Antimicrobial therapy covering colonic-type organisms (E. coli, Streptococcus faecalis, Klebsiella, Bacteroides, Clostridia) 1, 2
  • Ceftriaxone is FDA-approved for intra-abdominal infections including cholecystitis 3
  • Broad-spectrum coverage should include anaerobes, particularly in severely septic patients 4
• Analgesia for pain control (avoid morphine which causes sphincter of Oddi spasm; prefer meperidine/pethidine) 2, 4
• NPO status (nothing by mouth) until surgery 2

Definitive Surgical Treatment

Timing and Approach

Laparoscopic cholecystectomy should be performed within 72 hours of diagnosis, with acceptable extension up to 7-10 days from symptom onset. 1, 2

The benefits of early surgery include:

• Shorter recovery time and hospitalization 1
• Lower hospital costs 1
• Fewer work days lost 1
• Greater patient satisfaction 1
• Reduced risk of recurrent gallstone-related complications 1

Technical Considerations

• Laparoscopic approach is preferred over open surgery in all patients, including the elderly and high-risk populations 1, 5
• Risk factors predicting possible conversion to open surgery include: age >65 years, male gender, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery 1
• Conversion to open surgery is not a failure but a valid safety measure when anatomical clarity cannot be achieved 1, 6

High-Risk and Critically Ill Patients

Even in high-risk patients, immediate laparoscopic cholecystectomy is superior to percutaneous transhepatic gallbladder drainage (PTGBD) and is associated with fewer major complications. 1

When Surgery is Absolutely Contraindicated

For patients who are truly unfit for surgery (septic shock, prohibitive operative risk):

• Percutaneous cholecystostomy converts a septic patient into a non-septic patient by decompressing infected bile 1, 7
• Endoscopic gallbladder drainage is an alternative to percutaneous drainage 7
• These drainage procedures should be viewed as bridges to eventual cholecystectomy, not definitive treatment 8, 7

Post-operative Antimicrobial Therapy

For uncomplicated cholecystitis with complete source control (successful cholecystectomy), no postoperative antimicrobial therapy is necessary. 1, 6

Critical Pitfalls to Avoid

• Do not delay surgery hoping for spontaneous resolution in symptomatic patients—this only increases complication risk and eventual emergency surgery rates 9
• Do not assume high-risk patients cannot tolerate laparoscopy—laparoscopic approach has lower morbidity than open surgery even in elderly populations 1, 9
• Do not pursue conservative management as definitive treatment—30% develop recurrent complications and 60% eventually require cholecystectomy anyway 1, 6
• Conservative treatment with antibiotics alone should be regarded as a bridge to surgery, not a definitive solution, due to frequent recurrence and risk of disease progression requiring emergency operation 8

Conservative Management (Only When Surgery Must Be Delayed)

If surgery must be delayed beyond 10 days from symptom onset:

• Wait at least 6 weeks before performing interval cholecystectomy to allow inflammation to resolve 2
• Continue supportive care with fluids, analgesia, and antibiotics 1, 8
• Recognize that this approach carries substantial risk: approximately 8% may require emergency surgery due to disease progression 8