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 in elderly patients (>65 years) as it is associated with lower 2-year mortality (15.2%) compared to nonoperative management (29.3%) 4
• Age alone is not a contraindication for surgery 1
• Immediate laparoscopic cholecystectomy is superior to percutaneous drainage even in high-risk patients 2

Pregnant Patients

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

Critically Ill or Unfit for Surgery

• Percutaneous cholecystostomy (gallbladder drainage) is reserved only for patients who are critically ill with multiple comorbidities and truly unfit for any surgical intervention 1, 2
• However, be aware that percutaneous cholecystostomy has higher complication rates (65%) compared to laparoscopic cholecystectomy (12%) 4
• Cholecystostomy should be viewed as a bridge to eventual surgery rather than definitive treatment, as 76% of conservatively managed patients eventually require cholecystectomy 6

Perioperative Medical Management

Before Surgery

• Intravenous fluid resuscitation for hydration 3
• Antimicrobial therapy to control infection 2, 3
• Multimodal analgesia (see pain management section below) 7

After Surgery

• For uncomplicated cholecystitis with complete source control, no postoperative antimicrobial therapy is necessary 1, 2

Pain Management Algorithm

Severe Pain

• Opioids (morphine or equivalent) are the primary treatment for severe pain 7
• Use patient-controlled analgesia (PCA) when IV route is needed in cognitively intact patients 7
• Begin with bolus injection in opioid-naïve patients 7

Multimodal Analgesia Components

• Acetaminophen 1g every 6 hours as part of multimodal regimen 7
• IV acetaminophen may provide better analgesia than IV tramadol in laparoscopic cholecystectomy patients 7
• Preemptive acetaminophen (before surgery) reduces opiate side effects and hospital length of stay 7
• NSAIDs for moderate pain alone or to reduce morphine consumption in combination therapy 7

Adjunctive Medications

• Gabapentinoids (gabapentin, pregabalin) can be added as components of multimodal analgesia 7
• Alpha-2-agonists have sympatholytic effects that reduce opiate requirements 7

Conservative Management: When and Why to Avoid

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

• 30% of conservatively treated patients develop recurrent gallstone-related complications 2, 5
• 60% eventually undergo cholecystectomy anyway 2, 5
• 36% require hospital readmission, with 83% readmitted before eventual cholecystectomy 6
• 8% require emergency operations due to disease progression under conservative treatment 6

Only Consider Conservative Management If:

• Patient absolutely refuses surgery 1
• Patient is critically ill and truly unfit for any surgical intervention (then use cholecystostomy as bridge) 1, 2
• If delayed surgery is chosen, wait at least 6 weeks after clinical presentation 3

Complications Requiring Immediate 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 7

Common Pitfalls to Avoid

• Do not delay surgery beyond 7-10 days thinking the patient will "cool down"—this increases complications and readmissions 2, 6
• Do not routinely choose percutaneous cholecystostomy over surgery in elderly patients—surgery has better outcomes even in this population 4
• Do not withhold surgery in pregnant patients—it is safe in all trimesters and prevents maternal-fetal complications 4
• Do not continue postoperative antibiotics if source control was complete—this is unnecessary 1, 2