What is the treatment for cholecystitis?

Treatment of Acute Cholecystitis

Definitive Treatment: Early Laparoscopic Cholecystectomy

Early laparoscopic cholecystectomy performed within 72 hours of diagnosis (and up to 7-10 days from symptom onset) is the gold standard treatment for acute cholecystitis and should be performed in all operable patients. 1, 2, 3

Why Early Surgery is Superior

• Early laparoscopic cholecystectomy is associated with shorter hospital stays (5.4 days vs 10.0 days for delayed surgery), lower hospital costs, fewer work days lost, and greater patient satisfaction compared to delayed cholecystectomy. 1, 2, 3

• Early surgery reduces the risk of recurrent gallstone-related complications during the waiting period—approximately 30% of conservatively managed patients develop recurrent complications and 60% eventually require cholecystectomy anyway. 2

• Composite postoperative complications are significantly lower with early surgery (11.8%) compared to late surgery performed after 3 days (34.4%). 3

Initial Medical Management Before Surgery

While preparing for early cholecystectomy, initiate the following within the first hours of admission: 4, 5

• NPO (fasting) status 4
• Intravenous fluid resuscitation 4
• Antimicrobial therapy (see antibiotic section below) 4
• Analgesics for pain control 6, 4

Antibiotic Therapy

For Uncomplicated Cholecystitis (Stable, Immunocompetent Patients)

First-line: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours 4

Alternatives: Ceftriaxone plus metronidazole, or ticarcillin/clavulanate 4

For Complicated Cholecystitis (Critically Ill/Immunocompromised)

First-line: Piperacillin/tazobactam 4g/0.5g IV every 6 hours or 16g/2g continuous infusion 4

Alternatives: Ertapenem or tigecycline 4

Postoperative Antibiotic Duration

• For uncomplicated cholecystitis with complete source control: NO postoperative antibiotics are required. 1, 4, 2

• For complicated cholecystitis with adequate source control: Maximum 4 days for immunocompetent patients, 7 days for immunocompromised or critically ill patients. 4

Pain Management Algorithm

For moderate to severe pain, opioids are the primary treatment, with multimodal analgesia to reduce opioid requirements: 6

1. Initiate opioid therapy (morphine or equivalent) for severe pain 6
2. Add acetaminophen 1g IV every 6 hours as part of multimodal regimen 6
3. Add NSAIDs for moderate pain to reduce morphine consumption 6
4. Consider patient-controlled analgesia (PCA) for ongoing severe pain in cognitively intact patients, starting with bolus injection in opioid-naïve patients 6
5. Consider gabapentinoids (gabapentin, pregabalin) or alpha-2-agonists for refractory pain 6

Special Populations and Alternative Treatments

Elderly Patients (>65 Years)

Age alone is NOT a contraindication to laparoscopic cholecystectomy—elderly patients benefit from early surgery when fit for operation, though age >65 is a risk factor for conversion to open surgery. 1, 2, 3

• Laparoscopic cholecystectomy in patients >65 years is associated with lower 2-year mortality (15.2%) compared to nonoperative management (29.3%). 3

Pregnant Patients

Early laparoscopic cholecystectomy is recommended during all trimesters of pregnancy and is associated with significantly lower maternal-fetal complications (1.6%) compared to delayed management (18.4%). 3

Critically Ill or High-Risk Surgical Candidates

For patients unfit for surgery due to critical illness or multiple comorbidities, percutaneous cholecystostomy is a safe and effective alternative. 1, 4, 2

• However, percutaneous cholecystostomy has higher postprocedural complication rates (65%) compared to laparoscopic cholecystectomy (12%), so surgery remains preferred when feasible. 3

• Cholecystostomy converts a septic patient into a non-septic patient by decompressing infected bile or pus. 2

• Endoscopic transpapillary gallbladder drainage (ETGBD) or EUS-guided drainage (EUS-GBD) are alternative drainage options in specialized centers. 7

Risk Factors for Conversion to Open Surgery

The following factors predict higher conversion rates from laparoscopic to open cholecystectomy (but are NOT contraindications to attempting laparoscopy): 1, 2

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

Conversion to open surgery is not a failure but a valid safety option when necessary. 2

Gallbladder Perforation

Early diagnosis and immediate surgical intervention for gallbladder perforation substantially decreases morbidity (which can reach 12-16% mortality if delayed). 1

• Gallbladder perforation occurs in 2-11% of acute cholecystitis cases. 1

• Type I (free perforation with generalized peritonitis) and Type II (pericholecystic abscess) require urgent surgical intervention. 1

Concomitant Biliary Conditions

For concomitant choledocholithiasis or cholangitis, perform ERCP for biliary decompression; consider MRC for evaluating the common bile duct. 4

Common Pitfalls to Avoid

• Do not delay surgery beyond 72 hours in operable patients—the "golden window" for optimal outcomes is within 3 days of diagnosis. 4, 2, 3

• Do not withhold surgery from elderly patients based solely on age—they benefit significantly from early intervention. 2, 3

• Do not continue antibiotics postoperatively in uncomplicated cases with complete source control—this is unnecessary and promotes resistance. 1, 4, 2

• Do not choose percutaneous cholecystostomy over surgery in patients who can tolerate laparoscopy—surgery has better outcomes. 3