What is the treatment for cholecystitis?

Treatment of Cholecystitis

Early laparoscopic cholecystectomy within 72 hours of diagnosis (and up to 7-10 days from symptom onset) is the definitive treatment for acute cholecystitis, offering superior outcomes compared to delayed surgery or conservative management. 1, 2

Initial Medical Management

Before surgery, patients require stabilization with:

• Intravenous fluid resuscitation for hydration 1
• Fasting (NPO status) 1
• Antimicrobial therapy (see antibiotic section below) 1, 2
• Analgesics as needed for pain control 3

Antibiotic Therapy

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 4, 1, 2
• Complicated cholecystitis with adequate source control: Maximum 4 days for immunocompetent patients, 7 days for immunocompromised or critically ill 1

Surgical Management Algorithm

Timing of Surgery

Early laparoscopic cholecystectomy should be performed:

• Within 72 hours of diagnosis (optimal window) 1, 5
• Up to 7-10 days from symptom onset (acceptable extended window) 4, 2, 3

For patients presenting >10 days after symptom onset: Delayed cholecystectomy after 45 days is preferable unless signs of worsening peritonitis or sepsis warrant emergency intervention 4

Benefits of Early Surgery

Early laparoscopic cholecystectomy compared to delayed surgery results in:

• Shorter recovery time and hospitalization 4, 2
• Lower hospital costs 4, 2
• Fewer work days lost 4, 2
• Greater patient satisfaction 4, 2
• Reduced risk of recurrent gallstone-related complications 2
• Fewer composite postoperative complications (11.8% vs 34.4% for delayed surgery) 5

Laparoscopic vs Open Approach

• Laparoscopic cholecystectomy is the first-choice approach where adequate resources and skills are available 4, 2
• Open cholecystectomy remains feasible in resource-limited settings or when conversion is necessary for patient safety 4

Risk Factors for Conversion to Open Surgery

The following factors predict increased risk of conversion from laparoscopic to open approach:

• Age >65 years 4, 2
• Male gender 4, 2
• Thickened gallbladder wall 4, 2
• Diabetes mellitus 4, 2
• Previous upper abdominal surgery 4, 2

Important caveat: Age >65 years is NOT a contraindication to surgery; elderly patients benefit from early cholecystectomy when fit for surgery 2

Special Populations and Situations

Critically Ill or High-Risk Surgical Patients

Cholecystostomy (percutaneous gallbladder drainage) is indicated for:

• Patients with multiple comorbidities unfit for surgery 4
• Critically ill patients 4, 1
• Patients with exceptionally high perioperative risk 5

However, note this important caveat: Laparoscopic cholecystectomy is superior to percutaneous drainage even in high-risk patients, with fewer major complications (12% vs 65%) 2, 5. Cholecystostomy should be reserved for those truly unfit for any surgical intervention 4

Pregnant Women

• Early laparoscopic cholecystectomy is recommended during all trimesters 5
• Compared to delayed management, early surgery reduces maternal-fetal complications (1.6% vs 18.4%) 5

Gallbladder Perforation

• Immediate surgical intervention is mandatory when perforation is diagnosed 4, 2
• Early diagnosis and prompt surgery substantially decrease morbidity (12-16% mortality if delayed) 4

Concomitant Choledocholithiasis or Cholangitis

• ERCP for biliary decompression is recommended 1
• MRC may be considered for evaluating the common bile duct 1

Conservative Management Considerations

Conservative management (antibiotics, fluids, analgesics) without surgery should be avoided as definitive treatment because:

• Approximately 30% develop recurrent gallstone-related complications 2
• Approximately 60% eventually require cholecystectomy 2
• Risk of disease progression requiring emergency surgery persists 6

Conservative treatment should be regarded as a bridge to surgery rather than definitive solution 6

Diagnostic Approach

Clinical Features

• Right upper quadrant pain, fever, and leukocytosis 4, 2

Imaging

• Ultrasound is the first-choice investigation 4, 2
• Typical findings: pericholecystic fluid, distended gallbladder, edematous gallbladder wall, gallstones, positive Murphy's sign 4, 2
• Sensitivity approximately 81%, specificity approximately 83% 5
• Hepatobiliary scintigraphy is the gold standard when ultrasound is non-diagnostic 5

Key Clinical Pitfalls

• Do not delay surgery beyond 72 hours unless patient is truly unfit—outcomes worsen with delayed intervention 5
• Do not withhold surgery from elderly patients based on age alone—they benefit from early cholecystectomy when medically stable 2
• Do not continue antibiotics postoperatively for uncomplicated cases with complete source control 4, 1
• Do not rely on conservative management as definitive treatment—high recurrence rates mandate eventual surgery in most cases 2, 6