What is the treatment for a patient with acalculous cholecystitis and ascites?

Treatment of Acalculous Cholecystitis with Ascites

Early laparoscopic cholecystectomy remains the definitive treatment for acalculous cholecystitis even in patients with ascites who are suitable surgical candidates, as it provides superior outcomes compared to drainage procedures alone. 1, 2

Primary Treatment Algorithm

For surgical candidates with acalculous cholecystitis and ascites:

• Proceed with early laparoscopic cholecystectomy within 7-10 days of symptom onset, as this approach significantly reduces complications (5% vs 53% with drainage), shortens hospital stays, and decreases healthcare costs compared to percutaneous drainage or delayed management 1, 2
• The presence of ascites alone should not be considered an absolute contraindication to surgery, as evidence demonstrates that early surgical intervention is safe and effective even in high-risk patients 1, 2
• Laparoscopic cholecystectomy converts the patient from a septic to non-septic state definitively, whereas drainage procedures only temporize 3, 2

Management for Non-Surgical Candidates

If the patient is truly not a surgical candidate due to severe decompensated cirrhosis, hemodynamic instability, or prohibitive surgical risk:

• Perform percutaneous transhepatic gallbladder drainage (PTGBD) as the initial intervention for patients with sepsis from gallbladder empyema, which has an 85.6% success rate and only 0.36% procedure-related mortality 3, 2
• PTGBD effectively decompresses infected bile/pus and converts septic patients to non-septic status 3, 2
• Consider endoscopic alternatives (transpapillary gallbladder drainage or EUS-guided transmural drainage) only in high-volume centers with skilled endoscopists, as these show technical success rates of 86-97% 3, 2
• If metal stents are used for EUS-guided drainage, remove them within 4 weeks to prevent food impaction and recurrent cholecystitis 3

Risk Stratification for Treatment Decisions

Predictors of failure of conservative management that mandate intervention within 24-48 hours include:

• Age >70 years 3, 2
• Diabetes mellitus 3, 2
• Tachycardia 3, 2
• Distended gallbladder on imaging 3, 2
• WBC >15,000 cells/mm³ at 48 hours 2
• Persistent fever at 48 hours 2

Antibiotic Management

• Initiate broad-spectrum empiric antibiotics covering Gram-negative aerobes (E. coli, Klebsiella) and anaerobes (Bacteroides fragilis) 3, 4
• In patients with ascites from cirrhosis or immunosuppression, add enterococcal coverage as these patients have higher risk of Enterococcus infections 3
• Discontinue antibiotics after successful cholecystectomy in uncomplicated cases, as postoperative antibiotics are not routinely indicated once source control is achieved 3

Delayed Cholecystectomy Considerations

For patients initially managed with drainage:

• Perform delayed laparoscopic cholecystectomy after clinical stabilization to reduce the 49% one-year readmission rate seen in patients who never undergo definitive surgery 3, 2
• Only 40% of patients who undergo initial drainage eventually receive cholecystectomy, leaving the majority at risk for recurrent disease 3, 2

Critical Pitfalls to Avoid

• Do not delay surgery based solely on the presence of ascites or advanced age without assessing actual surgical risk, as this leads to higher mortality, longer hospitalizations, and increased readmissions 1, 2
• Avoid overusing drainage procedures in patients who could safely undergo surgery, as the 30-day mortality after drainage is 15.4% with morbidity rates ranging from 8.2-62% 3
• Recognize that acalculous cholecystitis has higher rates of gangrenous cholecystitis (31.2%) compared to calculous disease, making early definitive treatment even more critical 5
• Do not assume ascites automatically makes a patient "too high risk" for surgery—the CHOCOLATE trial demonstrated that even critically ill patients (APACHE 7-14) benefit from early cholecystectomy over drainage 3