What is the treatment for acute cholecystitis?

Treatment of Acute Cholecystitis

Early laparoscopic cholecystectomy within 72 hours of diagnosis is the definitive treatment for acute cholecystitis, with an acceptable window extending to 7-10 days from symptom onset. 1, 2

Initial Medical Management (Pre-operative Stabilization)

Before proceeding to surgery, initiate the following:

• Fasting status with intravenous fluid resuscitation for hydration 2, 3
• Empirical antibiotic therapy based on disease severity 1, 2, 4
• Analgesia as needed for pain control 1, 3

Antibiotic Selection

For uncomplicated cholecystitis in stable, immunocompetent patients:

• First-line: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours 2
• Alternatives: Ceftriaxone plus metronidazole, or ticarcillin/clavulanate 2
• Anaerobic coverage is NOT required unless biliary-enteric anastomosis is present 1
• Enterococcal coverage is NOT required for community-acquired infections in immunocompetent patients 1

For complicated cholecystitis or critically ill/immunocompromised patients:

• First-line: Piperacillin/tazobactam 4g/0.5g IV every 6 hours (or 16g/2g continuous infusion) 2
• Alternatives: Ertapenem or tigecycline 2

Definitive Surgical Management

Timing and Approach

• Perform laparoscopic cholecystectomy within 72 hours of diagnosis (optimal window) 1, 2, 3
• Acceptable extension: up to 7-10 days from symptom onset 1, 3
• Laparoscopic approach is preferred over open cholecystectomy in all suitable candidates 1, 5

Benefits of Early Surgery

Early laparoscopic cholecystectomy provides multiple advantages over delayed surgery:

• 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 (30% recurrence rate with conservative management) 1, 6

Risk Factors for Conversion to Open Surgery

Be aware that the following factors increase conversion risk, though conversion is not a failure but a valid safety option:

• Age >65 years 1, 6
• Male gender 1, 6
• Thickened gallbladder wall 1, 6
• Diabetes mellitus 1, 6
• Previous upper abdominal surgery 1, 6

Important caveat: Age >65 years is NOT a contraindication for laparoscopic cholecystectomy 1

Post-operative Antibiotic Management

For uncomplicated cholecystitis with complete source control:

• Discontinue antibiotics within 24 hours post-operatively 1, 2
• No further antibiotic therapy is required 1, 2, 6

For complicated cholecystitis with adequate source control:

• Maximum duration: 4 days for immunocompetent patients 2
• Maximum duration: 7 days for immunocompromised or critically ill patients 2

Alternative Management for High-Risk Patients

When Surgery is Not Feasible

For patients unfit for surgery (critically ill, multiple comorbidities, septic):

• Percutaneous cholecystostomy is the preferred alternative 1, 2, 7, 8
• Percutaneous transhepatic gallbladder drainage (PTGBD) decompresses infected bile/pus and converts septic patients to non-septic status 1
• However, immediate laparoscopic cholecystectomy is superior to PTGBD even in high-risk patients when feasible 1
• Laparoscopic cholecystectomy has fewer major complications compared to PTGBD in critically ill patients 1

Other drainage options:

• Endoscopic transpapillary gallbladder drainage (ETGBD) for selected cases in high-volume centers 8
• EUS-guided drainage (EUS-GBD) with potential advantages in reintervention rates 8

Delayed Surgery Approach

• If early laparoscopic cholecystectomy is not possible, delay surgery at least 6 weeks after clinical presentation 3
• After drainage and recovery, patients should be reconsidered for cholecystectomy as definitive treatment 7
• Long-term data shows 60% of conservatively managed patients eventually undergo cholecystectomy 1, 6

Special Situations

For concomitant choledocholithiasis or cholangitis:

• ERCP is recommended for biliary decompression 2
• Consider magnetic resonance cholangiography (MRC) for common bile duct evaluation 2

Common pitfall to avoid: Do not delay definitive surgical treatment in appropriate candidates, as mortality increases with age and comorbidity, and can reach 10-20% when combined with bacteremia 7, 4