What is the current management approach for acute cholecystitis?

Management of Acute Cholecystitis

Early laparoscopic cholecystectomy within 72 hours of diagnosis (up to 7-10 days from symptom onset) is the definitive treatment for acute cholecystitis, with immediate antibiotic therapy initiated while arranging surgery. 1, 2

Immediate Management Upon Diagnosis

Antibiotic Therapy

• Start Amoxicillin/Clavulanate 2g/0.2g IV every 8 hours immediately for immunocompetent, non-critically ill patients with community-acquired acute cholecystitis 2, 3
• For beta-lactam allergies, use Eravacycline 1 mg/kg IV every 12 hours OR Tigecycline 100 mg loading dose then 50 mg IV every 12 hours 2, 3
• For critically ill or immunocompromised patients, escalate to Piperacillin/Tazobactam 4g/0.5g IV every 6 hours or 16g/2g by continuous infusion 3
• For patients at risk of ESBL-producing organisms (healthcare-associated infections, recent antibiotic exposure), use Ertapenem 1g IV every 24 hours 3
• Continue antibiotics until surgical intervention is performed 2

Supportive Care

• IV fluid resuscitation 2
• Analgesia (avoid medications that mask clinical signs needed for monitoring) 2
• NPO status initially 4

Diagnostic Confirmation

• Ultrasound is the first-line imaging modality showing gallstones, wall thickening >3mm, pericholecystic fluid, and sonographic Murphy's sign with 92-95% positive predictive value 2, 3
• HIDA scan serves as gold standard if ultrasound is inconclusive, with 80-90% sensitivity for cystic duct obstruction 3
• Order MRCP if common bile duct stones are suspected based on: bilirubin >4 mg/dL, CBD diameter >6mm, or bilirubin 1.8-4 mg/dL 1, 3
• CT with IV contrast is reserved for suspected complicated cholecystitis or unclear diagnosis 2

Definitive Surgical Management

Timing of Surgery

• Perform early laparoscopic cholecystectomy within 72 hours of diagnosis as the optimal timeframe 2, 3, 5
• Acceptable extension up to 7 days of hospital admission and 10 days from symptom onset 1, 2
• If early surgery cannot be performed within this window, delay cholecystectomy to at least 6 weeks after clinical presentation 2, 4

Surgical Approach

• Laparoscopic cholecystectomy is the first-line surgical approach when adequate resources and expertise are available 1, 3, 5
• Give single-shot antibiotic prophylaxis if early intervention is performed 2
• Risk factors predicting conversion to open cholecystectomy include: age >65 years, male gender, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery 3, 5
• Conversion to open surgery is not a failure but a valid safety option 5

Postoperative Antibiotic Duration

Uncomplicated Cholecystitis

• No postoperative antibiotics are necessary when source control is adequate in immunocompetent, non-critically ill patients 1, 2, 3
• This applies regardless of age, including elderly patients 1, 3

Complicated Cholecystitis

• Maximum 4 days of antibiotic therapy for immunocompetent, non-critically ill patients with adequate source control 2, 3
• Up to 7 days for immunocompromised or critically ill patients based on clinical conditions and inflammatory markers 2, 3

Management of High-Risk and Unsuitable Surgical Candidates

High-Risk Patients (APACHE Score 7-14)

• Surgery remains superior to percutaneous drainage even in high-risk patients based on the CHOCOLATE trial 1
• Laparoscopic cholecystectomy is associated with fewer major complications compared to percutaneous transhepatic gallbladder drainage 5
• Develop local clinical pathways using validated scoring systems to identify these patients 1

Patients Not Suitable for Surgery

• This category includes patients unfit for surgery based on surgeon's clinical judgment and those with clinical conditions not classifiable by scores 1
• Percutaneous cholecystostomy is recommended for patients with multiple comorbidities unfit for surgery who do not improve after several days of antibiotic therapy 1, 2, 5
• Cholecystostomy converts a septic patient into a non-septic patient by decompressing infected bile 5
• Recognize that cholecystostomy is inferior to cholecystectomy in terms of major complications 2

Special Clinical Scenarios

Concomitant Choledocholithiasis/Cholangitis

• ERCP is the treatment of choice for biliary decompression in moderate/severe acute cholangitis 1, 3
• Percutaneous transhepatic biliary drainage (PTBD) is reserved for patients in whom ERCP fails 1
• Open drainage only for patients where endoscopic or percutaneous approaches are contraindicated or unsuccessful 1

Gallbladder Perforation

• Early diagnosis and immediate surgical intervention substantially decrease morbidity and mortality 1

Elderly Patients

• Age alone is not a contraindication for surgery; elderly patients benefit from early cholecystectomy when fit for surgery 1, 5
• Exercise caution with antibiotic selection due to altered pharmacokinetics/pharmacodynamics, renal effects of comorbidities (diabetes, heart failure, hypertension), and polypharmacy interactions 1
• Avoid aminoglycosides due to narrow therapeutic index and increased toxicity risk 1

Complicated Cholecystitis in Elderly

• Use broad-spectrum antibiotic regimens as empiric therapy, guided by most frequently isolated bacteria and local resistance patterns 1
• Empiric therapy is necessary as culture results take 48-72 hours 1
• Consider healthcare-associated multidrug-resistant organisms in institutionalized elderly patients 1

Critical Pitfalls to Avoid

• Do not use antibiotics as definitive conservative management—76% of conservatively treated patients eventually require cholecystectomy, with 36% requiring readmission 6
• Approximately 30% of conservatively managed patients develop recurrent gallstone complications within follow-up 5
• Do not delay surgery beyond 10 days from symptom onset unless deferring to 6+ weeks, as the intermediate period (10 days to 6 weeks) has worse outcomes 2, 4
• Do not routinely give postoperative antibiotics for uncomplicated cholecystitis—this does not decrease postoperative infection rates 1
• Recognize that 8% of patients initially managed conservatively may require emergency surgery due to disease progression 6