What is the treatment for cholecystitis?

From the Guidelines

Laparoscopic cholecystectomy is the recommended first-choice treatment for acute calculus cholecystitis (ACC) in high-risk patients, as it has been shown to be superior to percutaneous transhepatic gallbladder drainage (PTGBD) in terms of morbidity, mortality, and quality of life 1.

The treatment for cholecystitis typically involves hospitalization, antibiotics, pain management, and often surgical removal of the gallbladder. Initial management includes fasting to rest the gallbladder, intravenous fluids for hydration, and pain control with medications like morphine or hydromorphone. Antibiotic therapy should be started promptly, typically with regimens such as piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours, generally continuing for 4-7 days.

Key points to consider in the treatment of cholecystitis include:

• The importance of early laparoscopic cholecystectomy in high-risk patients, as it has been shown to reduce morbidity, mortality, and healthcare resource utilization 1
• The use of percutaneous cholecystostomy as a temporary measure in patients who cannot undergo immediate surgery due to severe inflammation or medical instability 2, 3, 4
• The need for careful patient selection and risk assessment to determine the best treatment approach for each individual patient 2, 3, 4

In terms of specific treatment recommendations, the following can be considered:

• Laparoscopic cholecystectomy should be performed within 24-72 hours of diagnosis for acute cases, if possible 1
• Percutaneous cholecystostomy can be considered as a bridge to cholecystectomy in acutely ill (high-risk) patients deemed unfit for surgery 3, 4
• Patients should follow a low-fat diet after recovery to prevent digestive discomfort, as the gallbladder's role in fat digestion is eliminated.

From the Research

Treatment for Cholecystitis

• The standard of care for patients with acute cholecystitis is early laparoscopic cholecystectomy 5, 6.
• Percutaneous cholecystostomy or endoscopic procedures are alternative treatments in selective cases, such as patients with an exceptionally high perioperative risk 5.
• Antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis 7, 8.
• The choice of antibiotic must be made considering factors such as the severity of the clinical manifestations, the onset of the infection, and any drug resistance 8.
• First-generation cephalosporins may be used empirically for mild-to-moderate acute cholecystitis without gallbladder perforation, and are not inferior to second-generation cephalosporins for prophylaxis against postoperative infection 9.
• The duration of antibiotic therapy should be limited to a maximum of four days, and perhaps a shorter duration in patients undergoing cholecystectomy for severe cholecystitis 7.

Antibiotic Regimens

• The most frequently isolated microorganisms in acute cholecystitis are Escherichia coli, Klebsiella spp., Streptococcus spp., Enterococcus spp., and Clostridium spp. 8.
• Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment 8.
• Therapy must be modified based on bile cultures in cases of severe cholecystitis 8.
• Antibiotic stewardship is the key to the correct management of bile-related infections, and it is necessary to be aware of the appropriate therapeutic scheme and its precise duration 8.

Special Populations

• In people older than 65 years of age, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up compared with nonoperative management 5.
• During pregnancy, early laparoscopic cholecystectomy is associated with a lower risk of maternal-fetal complications and is recommended during all trimesters 5.