From the Guidelines
Cholecystitis should be treated with early laparoscopic cholecystectomy within 7-10 days of onset of symptoms, as it is a safe and effective treatment that reduces hospital stay and improves patient outcomes. The diagnosis of cholecystitis is made on the basis of clinical features such as right upper quadrant pain, fever, and leukocytosis, and is supported by findings from relevant imaging studies, particularly ultrasound, which is the investigation of choice 1.
Diagnosis and Treatment
- The diagnosis is confirmed by ultrasound showing gallbladder wall thickening, pericholecystic fluid, or gallstones, and laboratory tests often reveal leukocytosis and elevated liver enzymes.
- Initial management includes NPO status, IV fluids, pain control with medications, and broad-spectrum antibiotics such as Piperacillin-Tazobactam or Ceftriaxone plus Metronidazole for 3-5 days.
- Definitive treatment is cholecystectomy, preferably laparoscopic, which is the first choice for patients with acute cholecystitis where adequate resources and skill are available 1.
- In high-risk surgical patients, percutaneous cholecystostomy may be performed as a temporizing measure, and is a safe and effective treatment for acute cholecystitis in critically ill and/or patients with multiple comorbidities and unfit for surgery 1.
Timing of Surgery
- Early laparoscopic cholecystectomy (ELC) is superior to delayed laparoscopic cholecystectomy (DLC) and intermediate laparoscopic cholecystectomy (ILC), with a shorter total hospital stay and faster return to work 1.
- ELC should be performed within 7 days of hospital admission and within 10 days of onset of symptoms, and is recommended for patients who are fit to undergo surgery 1.
Postoperative Care
- Post-cholecystectomy, patients should follow a low-fat diet initially and gradually return to normal eating.
- Antibiotic therapy should be limited to 4 days in immunocompetent patients with adequate source control, and up to 7 days in immunocompromised or critically ill patients 1.
From the Research
Diagnosis of Cholecystitis
- The diagnosis of acute cholecystitis is typically made based on clinical symptoms such as pain in the upper abdomen, fever, and leucocytosis, and confirmed using ultrasonography 2.
- The clinical diagnosis can be supported by laboratory and radiologic evidence, and in some cases, percutaneous cholecystostomy and bile cultures may be useful in diagnosing acute cholecystitis, especially in critically ill patients 3.
Treatment of Cholecystitis
- Laparoscopic cholecystectomy is widely recommended as the treatment of choice for acute cholecystitis, and should be performed as soon as possible after diagnosis, ideally within 72 hours of symptom onset 4, 2, 5.
- The optimal timeframe for performing early laparoscopic cholecystectomy (ELC) is within 72 hours from diagnosis, with a possible extension of up to 7-10 days from symptom onset 4.
- In patients who are not eligible for ELC, it is suggested to delay surgery at least 6 weeks after the clinical presentation 4.
- For critically ill patients who are unfit for surgery, percutaneous or endoscopic gallbladder drainage (GBD) may be considered as a rescue treatment 4, 3.
Antibiotic Use in Cholecystitis Treatment
- The use of peri-operative antibiotic agents is recommended for patients undergoing laparoscopic cholecystectomy for acute cholecystitis, but not for low-risk patients undergoing elective laparoscopic cholecystectomy 6.
- Post-operative antibiotic agents are not recommended after elective laparoscopic cholecystectomy for symptomatic cholelithiasis, or for patients undergoing laparoscopic cholecystectomy for mild or moderate acute cholecystitis 6.
- A maximum of four days of antibiotic agents is recommended, and perhaps a shorter duration in patients undergoing cholecystectomy for severe (Tokyo Guidelines grade III) cholecystitis 6.