What is the management and treatment for acute cholelithiasis?

Management of Acute Cholelithiasis

For acute cholecystitis, perform early laparoscopic cholecystectomy within 72 hours to 7 days of symptom onset, as this approach reduces hospital stay, recovery time, and costs compared to delayed surgery. 1, 2

Initial Diagnosis and Imaging

• Ultrasound is the first-line diagnostic modality, demonstrating gallstones, gallbladder wall thickening (>3mm), pericholecystic fluid, and sonographic Murphy's sign with 92-95% positive predictive value when combined with stones 1, 2
• Clinical diagnosis requires right upper quadrant pain, fever, and leukocytosis supported by imaging findings 1
• HIDA scan serves as the gold standard when ultrasound is inconclusive, with 80-90% sensitivity for cystic duct obstruction 2

Antibiotic Therapy

For stable, immunocompetent patients with community-acquired acute cholecystitis:

• First-line: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours 2
• Alternatives: Ceftriaxone plus metronidazole or Ticarcillin/clavulanate 2

For critically ill or immunocompromised patients:

• Piperacillin/tazobactam 4g/0.5g IV every 6 hours or 16g/2g by continuous infusion 2
• Ertapenem 1g IV every 24 hours for patients at risk of ESBL-producing organisms 2

Definitive Surgical Management

Early laparoscopic cholecystectomy is superior to delayed surgery and should be performed within 72 hours of diagnosis, with possible extension up to 7-10 days from symptom onset 1, 2. A meta-analysis of 16 studies involving 1,625 patients demonstrated that early laparoscopic cholecystectomy is as safe and effective as delayed surgery, with additional benefits of lower hospital costs, fewer work days lost, and greater patient satisfaction 1.

Risk factors predicting conversion to open cholecystectomy include age >65 years, male gender, acute cholecystitis, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery 1, 2. A meta-analysis of 14,645 patients identified these factors as significant predictors requiring surgical planning 1.

Open cholecystectomy remains a feasible alternative in low-resource settings or when laparoscopic expertise is unavailable 1.

Postoperative Antibiotic Duration

For uncomplicated cholecystitis with complete source control, no postoperative antibiotics are necessary 1, 2, 3. This recommendation applies to both young and elderly patients when adequate source control is achieved 2.

For complicated cholecystitis:

• Immunocompetent, non-critically ill patients: maximum 4 days of antibiotic therapy 2, 3
• Immunocompromised or critically ill patients: up to 7 days of antibiotic therapy 2

Management of Choledocholithiasis

When common bile duct stones are present alongside gallbladder stones, the approach differs:

ERCP with sphincterotomy and stone extraction is the mainstay of therapy, with a 90% success rate 1. This represents the standard of care, with ERCP utilization increasing from 75.2% to 96.1% for choledocholithiasis management between 1998-2013 1.

For large or impacted stones (>10-15mm):

• Lithotripsy or stone fragmentation may be required, with 79% success rate 1
• Multiple sessions may be needed in up to 30% of patients 1

For incomplete stone extraction or severe cholangitis:

• Internal plastic stent placement ensures adequate biliary drainage 1
• In biliary sepsis, percutaneous biliary decompression with internal/external drain placement can be lifesaving 1

MRCP should be performed to evaluate the common bile duct when concomitant choledocholithiasis/cholangitis is suspected 2.

Special Populations and Considerations

For critically ill patients or those with multiple comorbidities unfit for surgery:

• Cholecystostomy is a safe and effective alternative treatment 1

Common pitfalls to avoid:

• Do not delay surgery beyond 7-10 days in stable patients, as inflammation may worsen and increase conversion rates 1
• Do not routinely prescribe postoperative antibiotics for uncomplicated cases, as this provides no benefit and promotes resistance 1, 2, 3
• Be aware that elderly patients have significantly higher complication rates with ERCP (19% major complications, 7.9% mortality) compared to younger patients (6-10% complications) 1

For asymptomatic cholelithiasis (incidental finding without acute inflammation):

• Observation is appropriate for most patients, as progression to symptomatic disease occurs in only 10-25% of cases 4
• Cholecystectomy is reserved for symptomatic disease or high-risk populations 4