Treatment of Acute Cholecystitis
Laparoscopic cholecystectomy performed within 72 hours of diagnosis (or up to 7-10 days from symptom onset) is the definitive treatment for acute cholecystitis in all patients fit for surgery. 1, 2, 3
Initial Medical Management
Before surgery, patients require:
- Intravenous hydration and fasting 1
- Antibiotic therapy (see specific regimens below) 1
- Analgesics as needed 4
Antibiotic Regimens
For Uncomplicated Cholecystitis (Stable, Immunocompetent Patients)
- First-line: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours 1
- Alternatives: Ceftriaxone plus metronidazole, or ticarcillin/clavulanate 1
For Complicated Cholecystitis (Critically Ill/Immunocompromised)
- First-line: Piperacillin/tazobactam 4g/0.5g IV every 6 hours or 16g/2g continuous infusion 1
- Alternatives: Ertapenem or tigecycline 1
Postoperative Antibiotic Duration
- Uncomplicated cholecystitis with complete source control: NO postoperative antibiotics required 5, 1, 2
- Complicated cholecystitis with adequate source control: Maximum 4 days for immunocompetent patients, 7 days for immunocompromised/critically ill 1
Surgical Timing and Approach
Early laparoscopic cholecystectomy (ELC) is superior to delayed surgery because it results in:
- Shorter hospital stays (approximately 4 days shorter) 3
- Faster return to work (9 days sooner) 3
- Lower hospital costs 5, 2
- Reduced risk of recurrent biliary complications 2, 3
- Greater patient satisfaction 5, 2
Risk Factors for Conversion to Open Surgery
Be aware that the following factors increase conversion risk, though they are NOT contraindications to attempting laparoscopic approach 5, 2:
- Age >65 years
- Male gender
- Thickened gallbladder wall
- Diabetes mellitus
- Previous upper abdominal surgery
Conversion to open cholecystectomy is not a failure but a valid safety option when necessary. 2
Alternative Treatments for Non-Surgical Candidates
Percutaneous Cholecystostomy
For critically ill patients or those with multiple comorbidities unfit for surgery, cholecystostomy is safe and effective. 5, 1, 2
- Converts septic patients to non-septic by decompressing infected bile 2
- Can be performed with or without delayed cholecystectomy 5
Important Evidence on High-Risk Patients
Even in critically ill patients, immediate laparoscopic cholecystectomy is superior to percutaneous transhepatic gallbladder drainage (PTGBD), with the CHOCOLATE trial showing only 5% complications versus 53% with PTGBD, and significantly fewer recurrent biliary events. 3
Critical Complications Requiring Urgent Intervention
Gallbladder Perforation
Early diagnosis and immediate surgical intervention substantially decrease morbidity and mortality. 5
- Occurs in 2-11% of acute cholecystitis cases 5
- Mortality reaches 12-16% when perforation occurs 5
- Three types exist: Type I (free perforation with generalized peritonitis), Type II (pericholecystic abscess), Type III (cholecystoenteric fistula) 5
Concomitant Choledocholithiasis or Cholangitis
ERCP is recommended for biliary decompression, with MRC considered for common bile duct evaluation. 1
Common Pitfalls to Avoid
Do not delay surgery beyond 7-10 days from symptom onset in operative candidates, as this increases risk of recurrent complications. 2, 3
Do not continue antibiotics postoperatively in uncomplicated cases with complete source control—this represents unnecessary antibiotic exposure. 5, 1, 2
Do not assume conservative management is adequate—long-term follow-up shows 30% develop recurrent complications and 60% eventually require cholecystectomy anyway. 2, 3