What is the management of acalculous cholecystitis?

Management of Acalculous Cholecystitis

Laparoscopic cholecystectomy performed within 72 hours to 7-10 days of symptom onset is the definitive treatment for acalculous cholecystitis in hemodynamically stable surgical candidates, as it significantly reduces complications, mortality, and readmissions compared to conservative management or delayed intervention. 1, 2

Initial Stabilization and Resuscitation

• Begin immediate IV fluid resuscitation to correct dehydration and maintain hemodynamic stability 1
• Administer opioid analgesia for severe pain, preferably via patient-controlled analgesia (PCA) when IV route is needed 1
• Add multimodal analgesia with acetaminophen and NSAIDs for moderate pain 1

Diagnostic Imaging Approach

• Perform ultrasound as first-line imaging, specifically looking for pericholecystic fluid, distended gallbladder, edematous gallbladder wall (>5mm), and ultrasonographic Murphy's sign (sensitivity 80-90%) 1
• Obtain hepatic iminodiacetic acid (HIDA) scan when ultrasound is inconclusive (sensitivity 80-90%) 1

Antibiotic Management

Initiate broad-spectrum IV antibiotics within the first hour of recognition, as delayed therapy significantly increases mortality (35% in septic shock from biliary sources). 1

Antibiotic Selection by Patient Status:

Stable, immunocompetent patients:

• First-line: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours 2
• Alternatives: Tigecycline or eravacycline 3

Critically ill or immunocompromised patients:

• First-line: Piperacillin/tazobactam 4g/0.5g IV every 6 hours (or 16g/2g continuous infusion for critically ill) 1, 2

Antibiotics with efficient biliary penetration: Piperacillin/tazobactam, tigeciclina, amoxicillin/clavulanate, ciprofloxacin, ampicillin/sulbactam, ceftriaxone, levofloxacin 2

Antibiotic Duration:

• Uncomplicated cases with early surgery: Single-dose prophylaxis only; discontinue within 24 hours post-cholecystectomy when adequate source control is achieved 2, 3
• Complicated cases with adequate source control: 4 days for immunocompetent patients; up to 7 days for immunocompromised or critically ill patients 1, 2
• Obtain bile and gallbladder cultures intraoperatively to guide targeted therapy 1

Definitive Treatment Algorithm

For Surgical Candidates:

Perform laparoscopic cholecystectomy as soon as hemodynamically feasible, ideally within 72 hours to 7-10 days of symptom onset. 1, 2, 3

• Laparoscopic approach is superior to open surgery with shorter hospital stays, less pain, and faster recovery 3
• Early surgery results in significantly fewer complications compared to percutaneous drainage (5% vs 53%) 2
• Do NOT delay surgery based solely on age or comorbidities, as early laparoscopic cholecystectomy is safe and effective even in high-risk patients 2, 3

For Non-Surgical Candidates:

When patients are unfit for surgery based on clinical contraindications or surgeon judgment, percutaneous transhepatic gallbladder drainage (PTGBD) is the recommended alternative. 2, 3

• PTGBD has high success rate (85.6%) and low procedure-related mortality (0.36%) 2, 3
• PTGBD converts septic patients to non-septic by decompressing infected bile or pus 2
• Approximately 40% of patients undergoing PTGBD eventually require delayed laparoscopic cholecystectomy 2
• Patients who do not undergo subsequent cholecystectomy have 49% readmission rate at one year 2

Special Populations

Immunocompromised or Transplant Patients:

• Perform laparoscopic cholecystectomy as soon as possible after diagnosis 1, 3
• Continue antibiotics up to 7 days based on clinical conditions 1
• Laparoscopic approach should be preferred whenever possible 3

Elderly Patients (>70 years):

• Age >70 years is a predictor of conservative management failure (OR 3.6-5.2 at 24 hours, OR 5.2 at 48 hours) 1, 2
• Do NOT delay surgery based solely on age, as evidence shows early laparoscopic cholecystectomy is safe and effective 1, 2

Predictors of Conservative Management Failure

At 24 Hours:

• Tachycardia >100 bpm (OR 5.6) 1, 2, 3
• Distended gallbladder >5 cm transverse diameter (OR 8.5) 1, 2, 3
• Age >70 years (OR 3.6-5.2) 1, 2, 3

At 48 Hours:

• Leukocytosis >15,000 cells/mm³ (OR 13.7) 1, 2, 3
• Persistent fever 1, 2, 3
• Age >70 years (OR 5.2) 1, 2, 3

Critical Pitfalls to Avoid

• Do NOT delay surgery in surgical candidates based solely on age or comorbidities, as early laparoscopic cholecystectomy is safe and effective even in high-risk patients 2, 3
• Do NOT overuse percutaneous drainage in patients who could safely undergo surgery, as this leads to higher mortality rates, longer hospital stays, and more readmissions 2
• Do NOT discontinue antibiotics prematurely in patients with sepsis biliar, as biliary source of peritonitis is a risk factor for mortality in septic shock (OR 3.5) 2
• Do NOT continue antibiotics beyond 24 hours post-cholecystectomy when source control is adequate 2, 3