Treatment for Acute Cholecystitis
Early laparoscopic cholecystectomy 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 fit for surgery. 1, 2, 3
Initial Medical Management (Pre-operative Stabilization)
Start empirical antibiotic therapy immediately upon diagnosis, targeting Enterobacteriaceae (E. coli, Klebsiella) which colonize bile in 35-60% of cases 4
For uncomplicated cholecystitis in stable, immunocompetent patients: Use amoxicillin/clavulanate 2g/0.2g every 8 hours 1
For complicated cholecystitis or critically ill/immunocompromised patients: Use piperacillin/tazobactam 1, 2
Anaerobic coverage is NOT required unless a biliary-enteric anastomosis is present 2
Enterococcal coverage is NOT required for community-acquired infections in immunocompetent patients 2
Provide intravenous fluids, maintain fasting status, and administer analgesics as needed 5
Definitive Surgical Management
Timing is critical for optimal outcomes:
Ideal window: Perform laparoscopic cholecystectomy within 72 hours of diagnosis 2
Acceptable window: Up to 7 days from hospital admission or 10 days from symptom onset 1, 2, 3
Early surgery results in 4 days shorter hospital stay, 9 days sooner return to work, fewer serious adverse events, and reduced recurrent biliary complications compared to delayed surgery 3
Surgical approach:
Laparoscopic cholecystectomy is preferred over open surgery in all suitable candidates 2
Conversion to open surgery is not a failure but a valid safety option when necessary 2
Age >65 years is NOT a contraindication for laparoscopic cholecystectomy, though it increases conversion risk along with male gender, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery 2, 3
Post-operative Antibiotic Management
For uncomplicated cholecystitis with complete source control: Discontinue antibiotics within 24 hours post-operatively; no further therapy needed 1, 2, 3
For complicated cholecystitis: Short course postoperative antibiotics are required 3
Management of High-Risk Surgical Patients
For patients unfit for immediate surgery (critically ill, severe comorbidities, prohibitive surgical risk):
First-line alternative: Immediate laparoscopic cholecystectomy is STILL superior to percutaneous transhepatic gallbladder drainage (PTGBD) even in high-risk patients, with the CHOCOLATE trial showing only 5% complications versus 53% with PTGBD 2, 3
If surgery is truly contraindicated: Percutaneous cholecystostomy tube placement converts a septic patient into a non-septic patient by decompressing infected bile 2
Temporary bridge therapy: Antibiotic-only treatment or gallbladder drainage may be considered for patients requiring medical optimization before eventual surgical management 1
Delayed surgery option: If early cholecystectomy cannot be performed, delay surgery at least 6 weeks after clinical presentation 5
Critical Pitfalls to Avoid
Do not delay surgery beyond 10 days from symptom onset - approximately 30% of conservatively treated patients develop recurrent gallstone-related complications and 60% eventually require cholecystectomy anyway 2, 3
Do not withhold surgery based solely on age - elderly patients benefit from early cholecystectomy when fit for surgery 6, 2
Do not continue antibiotics postoperatively in uncomplicated cases - this promotes resistance without benefit 2
Do not assume PTGBD is safer than surgery in high-risk patients - recent high-quality evidence shows immediate surgery has better outcomes even in critically ill patients 2, 3