What is the treatment for cholecystitis?

Treatment of Cholecystitis

Early laparoscopic cholecystectomy performed within 7 days of hospital admission (and within 10 days of symptom onset) is the definitive treatment for acute cholecystitis and should be performed in all patients unless they are critically ill or have prohibitive surgical risk. 1, 2

Surgical Management: The Gold Standard

Timing of Surgery

• Perform laparoscopic cholecystectomy within 72 hours of diagnosis, with acceptable extension up to 7-10 days from symptom onset 2, 3, 4
• Early surgery (within 1-3 days) compared to delayed surgery results in:
  • Fewer postoperative complications (11.8% vs 34.4%) 4
  • Shorter hospital stay (5.4 days vs 10.0 days) 4
  • Lower hospital costs 1, 2
  • Fewer work days lost 1, 2
  • Greater patient satisfaction 1, 2
  • Reduced risk of recurrent gallstone-related complications 2

Laparoscopic vs Open Approach

• Laparoscopic cholecystectomy is the preferred approach for all patients with adequate resources and surgical expertise 1
• Conversion to open surgery is not a failure but a valid safety option when necessary 2, 5
• Risk factors predicting conversion to open surgery include: age >65 years, male gender, thickened gallbladder wall (>4mm), diabetes mellitus, and previous upper abdominal surgery 1, 2

Special Populations

Elderly and High-Risk Patients

• Laparoscopic cholecystectomy should still be performed even in elderly patients with comorbidities 6, 4
• In patients >65 years, laparoscopic cholecystectomy has lower 2-year mortality (15.2%) compared to nonoperative management (29.3%) 4
• Immediate laparoscopic cholecystectomy is superior to percutaneous drainage even in high-risk patients 2
• Age alone is not a contraindication for surgery 1

Pregnant Patients

• Early laparoscopic cholecystectomy is recommended during all trimesters of pregnancy 4
• Early surgery has lower maternal-fetal complications (1.6%) compared to delayed management (18.4%) 4

Critically Ill or Unfit for Surgery

• Percutaneous cholecystostomy (gallbladder drainage) is reserved only for patients who are critically ill or truly unfit for any surgical intervention 1, 2
• However, cholecystostomy has higher complication rates (65%) compared to laparoscopic cholecystectomy (12%) 4
• Cholecystostomy converts a septic patient into a non-septic patient by decompressing infected bile 2
• This should be considered a bridge to surgery, not definitive treatment, as 76% eventually require cholecystectomy 7

Perioperative Medical Management

Antimicrobial Therapy

• Initiate antimicrobial therapy before surgery 2
• For uncomplicated cholecystitis with complete source control at surgery, no postoperative antibiotics are necessary 1, 2

Pain Management

• Opioids are the primary treatment for severe pain 8
• Patient-controlled analgesia (PCA) is recommended for adequate pain control in cognitively intact patients 8
• Multimodal analgesia should include acetaminophen 1g every 6 hours 8
• NSAIDs are indicated for moderate pain and can reduce morphine consumption 8
• Consider gabapentinoids or alpha-2-agonists for refractory pain 8

Supportive Care

• Intravenous fluid resuscitation 3
• Nothing by mouth (NPO) status initially 3

Conservative Management: When and Why to Avoid

Conservative management with antibiotics, fluids, and analgesia should be avoided as definitive treatment because:

• 30% of conservatively treated patients develop recurrent gallstone-related complications 2
• 60% eventually undergo cholecystectomy anyway 2
• 36% require hospital readmission, mostly before eventual surgery 7
• 8% require emergency surgery due to disease progression despite conservative treatment 7

Conservative management may only be considered as a temporary measure in patients with mildly symptomatic acute cholecystitis who are awaiting optimization for surgery 2

Complications Requiring Urgent Intervention

Gallbladder Perforation

• Early diagnosis and immediate surgical intervention substantially decrease morbidity and mortality 1, 2
• Perforation occurs in 2-11% of acute cholecystitis cases with mortality up to 12-16% 1
• Patients with ongoing pain despite appropriate management should be evaluated for perforation or progression to severe cholecystitis 8

Common Pitfalls to Avoid

• Do not delay surgery beyond 7-10 days waiting for "inflammation to cool down" - this outdated approach increases complications and readmissions 2, 4
• Do not use age alone as a contraindication to surgery - elderly patients benefit from early cholecystectomy 1, 4
• Do not routinely choose percutaneous drainage over surgery in high-risk patients - immediate surgery is superior even in this population 2
• Do not consider conservative management as definitive treatment - it should only be a bridge to surgery 7