What is the immediate treatment and management guideline for a patient experiencing a gallbladder attack?

Immediate Management of Gallbladder Attack (Acute Cholecystitis)

For a patient experiencing a gallbladder attack, initiate immediate supportive care with IV fluids, NPO status, analgesia, and empiric antibiotics, followed by early laparoscopic cholecystectomy within 7-10 days of symptom onset, as this approach reduces hospital stay, complications, and recurrence compared to delayed surgery. 1, 2

Initial Emergency Department Management

Immediate Stabilization (First Hours)

• Make the patient NPO (nothing by mouth) immediately to rest the gallbladder and reduce stimulation of bile secretion 3
• Start intravenous fluid resuscitation for hydration, as patients are often volume depleted from nausea/vomiting and decreased oral intake 3, 4
• Administer appropriate analgesia for pain control; prostaglandin synthesis inhibitors may be particularly effective for acute biliary pain 5
• Initiate empiric antibiotic therapy given the significant mortality risk associated with biliary tract infections 2

Antibiotic Selection Based on Patient Risk

For immunocompetent, non-critically ill patients:

• Amoxicillin/Clavulanate 2g/0.2g IV every 8 hours 6

For critically ill or immunocompromised patients:

• Piperacillin/tazobactam 6g/0.75g loading dose, then 4g/0.5g every 6 hours (or 16g/2g by continuous infusion) 6

For beta-lactam allergy:

• Eravacycline 1 mg/kg every 12 hours OR Tigecycline 100 mg loading dose then 50 mg every 12 hours 6

Diagnostic Workup

Essential Imaging

• Ultrasound is the investigation of choice for suspected acute cholecystitis, showing gallstones, thickened gallbladder wall, and pericholecystic fluid 2
• CT with IV contrast may be used as an alternative if ultrasound is inconclusive or unavailable 2
• MRCP (magnetic resonance cholangiopancreatography) is recommended if common bile duct stones are suspected based on elevated bilirubin, dilated common bile duct on ultrasound, or cholangitis 2

Critical Pitfall to Avoid

Do not rely solely on classic findings—acute cholecystitis can present without fever, leukocytosis, or positive Murphy's sign. 4 A normal white blood cell count and only mildly elevated liver enzymes do not exclude the diagnosis. 4

Definitive Treatment: Timing is Critical

Early Laparoscopic Cholecystectomy (Preferred Approach)

Perform laparoscopic cholecystectomy as soon as possible, ideally within 72 hours of diagnosis and no later than 7-10 days from symptom onset. 2, 3, 7 This timing is crucial because:

• Early surgery (within 7 days) shortens total hospital stay by approximately 4 days compared to delayed surgery 2
• Patients return to work approximately 9 days sooner with early intervention 2
• Recurrent symptoms and complications occur frequently (60% recurrence rate) if surgery is delayed 2
• Laparoscopic cholecystectomy has >97% success rates with lower morbidity than open surgery 8

Antibiotic Duration with Surgery

• For uncomplicated cholecystitis with early cholecystectomy: single-shot prophylaxis only, no postoperative antibiotics 2, 8
• For complicated cholecystitis: 4 days of antibiotics if source control is adequate in immunocompetent non-critically ill patients 2
• For immunocompromised or critically ill patients: up to 7 days based on clinical response and inflammatory markers 2

Alternative Management for High-Risk Patients

When Surgery Must Be Delayed

If the patient is hemodynamically unstable, has severe sepsis, or has temporary contraindications to surgery, consider percutaneous cholecystostomy as a bridge procedure. 1, 7 However, recognize that:

• Cholecystostomy is inferior to cholecystectomy with major complication rates of 53% versus 5% 2, 8
• Cholecystostomy should only serve as a bridge to eventual cholecystectomy once the patient is stabilized, not as definitive treatment 8
• Even high-risk patients (ASA III/IV) benefit from laparoscopic cholecystectomy over drainage alone, with lower 2-year mortality 2

Delayed Surgery Protocol

If early surgery cannot be performed, delay cholecystectomy at least 6 weeks after clinical presentation to allow inflammation to subside, though this carries higher recurrence risk. 3

Special Populations Requiring Modified Approach

Pregnant Patients

• Laparoscopic cholecystectomy is safe in any trimester, ideally performed in the second trimester 2, 8
• Conservative management has a 60% recurrence rate of biliary symptoms during pregnancy 2
• For acute biliary pancreatitis in pregnancy, same-admission cholecystectomy reduces early readmission by 85% 2

Cirrhotic Patients

• Child-Pugh A and B: laparoscopic cholecystectomy is first choice 2
• Child-Pugh C or uncompensated cirrhosis: avoid cholecystectomy unless clearly indicated 2

Elderly Patients (>65 years)

• Age alone is NOT a contraindication to laparoscopic cholecystectomy 2, 8
• However, age >65 is a risk factor for conversion to open surgery, along with male gender, diabetes, and previous upper abdominal surgery 8

Complications Requiring Urgent Intervention

Gallbladder Perforation

Early diagnosis and immediate surgical intervention substantially decrease morbidity and mortality, which can reach 12-16% when treatment is delayed. 1, 8 Look for:

• Sudden worsening of pain followed by temporary improvement
• Signs of peritonitis on examination
• Free fluid or free air on imaging

Cholangitis (Ascending Infection)

ERCP is the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis. 1 If ERCP fails, percutaneous transhepatic biliary drainage (PTBD) should be performed. 1

Common Bile Duct Stones

Obtain MRCP if suspected (elevated bilirubin, dilated CBD, cholangitis). 2 Perform ERCP for stone extraction, ideally as a one-step procedure with simultaneous laparoscopic cholecystectomy. 7

What NOT to Do

• Do not observe and wait in symptomatic disease—this carries 6-10% annual recurrence of symptoms and 2% annual complication rate, with eventual need for surgery in worse clinical condition 2, 5
• Do not delay surgery beyond 10 days from symptom onset in uncomplicated cases—this increases conversion rates, complications, and hospital costs 2, 3
• Do not use cholecystostomy as definitive treatment in patients who could eventually tolerate surgery—it has significantly higher complication rates 2, 8
• Do not assume atypical presentations are not cholecystitis—absence of fever, normal WBC, and negative Murphy's sign do not exclude the diagnosis 4