What is the treatment for acute cholecystitis?

From the Guidelines

The treatment of acute cholecystitis in high-risk patients should be immediate laparoscopic cholecystectomy, as it is superior to percutaneous transhepatic gallbladder drainage (PTGBD) in terms of reducing morbidity, mortality, and improving quality of life. This recommendation is based on the most recent and highest quality study available, which is the 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis 1.

Initial Management

Initial treatment of acute cholecystitis includes bowel rest, intravenous fluids for hydration, pain control with medications, and broad-spectrum antibiotics such as piperacillin-tazobactam or a combination of ceftriaxone and metronidazole. These antibiotics target common biliary pathogens including E. coli, Klebsiella, and anaerobes.

Definitive Treatment

Definitive treatment is cholecystectomy, preferably laparoscopic, which should be performed within 24-72 hours of symptom onset for optimal outcomes. Early surgery reduces overall hospital stay and complication rates. The results of the CHOCOLATE trial, as mentioned in the guidelines, showed that laparoscopic cholecystectomy is superior to PTGBD also in high-risk patients with acute cholecystitis, with significantly fewer major complications and less utilization of healthcare resources 1.

Special Considerations

For patients who are poor surgical candidates due to severe comorbidities or critical illness, percutaneous cholecystostomy tube placement may be considered as a temporary measure to provide drainage until the patient can tolerate surgery or as a definitive treatment in those who cannot undergo surgery. However, this approach should be used judiciously, as it may lead to longer preoperative and overall hospital stays, and potentially more complicated surgeries due to adhesions and anatomical difficulties 1.

Key Points

• Immediate laparoscopic cholecystectomy is the preferred treatment for high-risk patients with acute cholecystitis.
• Broad-spectrum antibiotics and supportive care are essential components of initial management.
• Percutaneous cholecystostomy may be considered in select cases where surgery is not immediately feasible.
• Early surgery is associated with better outcomes in terms of morbidity, mortality, and quality of life.

From the FDA Drug Label

INTRA-ABDOMINAL INFECTIONS Caused by Escherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, Clostridium species (Note: most strains of Clostridium difficile are resistant) or Peptostreptococcus species. SURGICAL PROPHYLAXIS The preoperative administration of a single 1 gram dose of Ceftriaxone for Injection may reduce the incidence of postoperative infections in patients undergoing surgical procedures classified as contaminated or potentially contaminated (e.g., vaginal or abdominal hysterectomy or cholecystectomy for chronic calculous cholecystitis in high-risk patients, such as those over 70 years of age, with acute cholecystitis not requiring therapeutic antimicrobials, obstructive jaundice or common duct bile stones)

Treatment of acute cholecystitis may include ceftriaxone as part of the management, particularly for the coverage of susceptible organisms such as Escherichia coli and Klebsiella pneumoniae.

• The use of ceftriaxone in intra-abdominal infections suggests its potential efficacy in acute cholecystitis.
• Surgical prophylaxis with ceftriaxone may be considered in patients undergoing cholecystectomy, especially in high-risk cases. 2

From the Research

Treatment Options for Acute Cholecystitis

• Early laparoscopic cholecystectomy (ELC) is considered the best treatment for acute cholecystitis, with the optimal timeframe for performing ELC being within 72 hours from diagnosis 3.
• In patients who are not eligible for ELC, surgery may be delayed at least 6 weeks after clinical presentation 3.
• For critically ill patients who are unfit for surgery, rescue treatments such as percutaneous or endoscopic gallbladder drainage (GBD) may be required 3.

Medical Management

• Before undergoing ELC, patients typically receive medical management comprising fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics 3.
• Antimicrobial therapy is crucial in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis 4.
• The choice of antibiotic must consider factors such as the severity of clinical manifestations, the onset of infection, and drug resistance 4.

Alternative Treatment Approaches

• Percutaneous cholecystostomy (PC) followed by interval laparoscopic cholecystectomy is a safe and minimally invasive approach for critically ill patients with contraindications to emergency surgery 5.
• Endoscopic transpapillary drainage with or without gallstone dissolution has been demonstrated to be an effective alternative to surgery in high-risk patients with acute calculous cholecystitis 6.

Antibiotic Use

• The Surgical Infection Society recommends against routine use of peri-operative antibiotic agents in low-risk patients undergoing elective laparoscopic cholecystectomy, but recommends their use in patients undergoing laparoscopic cholecystectomy for acute cholecystitis 7.
• The recommended duration of antibiotic agents is a maximum of four days, and perhaps a shorter duration in patients undergoing cholecystectomy for severe cholecystitis 7.