What is the recommended course of action for a patient experiencing a gallbladder (cholecystitis) attack?

Management of Acute Cholecystitis (Gallbladder Attack)

Proceed immediately with early laparoscopic cholecystectomy within 72 hours of diagnosis (acceptable up to 7-10 days from symptom onset), as this is the definitive treatment that reduces complications, shortens hospital stay, and prevents recurrent gallstone-related events. 1, 2, 3

Initial Diagnostic Confirmation

• Obtain right upper quadrant ultrasound as the first-line imaging study, looking for gallbladder wall thickening, pericholecystic fluid, gallstones, and sonographic Murphy's sign (sensitivity ~81%, specificity ~83%). 2, 3
• If ultrasound is non-diagnostic, proceed with hepatobiliary scintigraphy (HIDA scan), which is the gold standard for confirming cystic duct obstruction. 2, 4, 3
• Consider CT with IV contrast if complications such as perforation or abscess are suspected. 2

Immediate Medical Management (Pre-Operative Stabilization)

• Initiate IV fluid resuscitation and maintain NPO status. 5
• Administer single-dose antibiotic prophylaxis if surgery will occur within 24-48 hours—no postoperative antibiotics are needed for uncomplicated cholecystitis when adequate source control is achieved. 1, 2
• Provide analgesics for pain control (prostaglandin synthesis inhibitors may be particularly effective). 6

Definitive Surgical Management

Early laparoscopic cholecystectomy (within 72 hours, up to 7-10 days maximum) is superior to delayed surgery across all outcomes: 1, 2, 3

• Fewer composite postoperative complications (11.8% vs 34.4% for delayed surgery). 3
• Shorter hospital stay (5.4 days vs 10.0 days). 3
• Lower total hospital costs and fewer work days lost. 1
• Critical pitfall: Delaying surgery beyond 10 days significantly increases complication rates and recurrence risk. 1

For Uncomplicated Cholecystitis:

• Perform laparoscopic cholecystectomy with single-dose prophylactic antibiotics only. 2, 1
• No postoperative antibiotics are required when source control is adequate—continuing antibiotics provides no benefit and promotes resistance. 1, 2

For Complicated Cholecystitis (gangrenous, emphysematous, or perforated):

• Proceed with laparoscopic cholecystectomy (open conversion if necessary). 2
• Administer antibiotics for 4 days in immunocompetent, non-critically ill patients if source control is adequate. 2
• Extend antibiotics up to 7 days based on clinical response and inflammatory markers in immunocompromised or critically ill patients. 2
• Patients with ongoing infection beyond 7 days warrant diagnostic investigation for inadequate source control. 2

Antibiotic Selection

For Non-Critically Ill, Immunocompetent Patients:

• Amoxicillin/clavulanate 2g/0.2g IV q8h (first-line). 2
• For documented beta-lactam allergy: Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose, then 50 mg q12h. 2

For Critically Ill or Immunocompromised Patients:

• Piperacillin/tazobactam 6g/0.75g loading dose, then 4g/0.5g q6h (or 16g/2g continuous infusion). 2, 1
• For inadequate/delayed source control or high risk of ESBL-producing organisms: Ertapenem 1g q24h or Eravacycline 1 mg/kg q12h. 2

For Septic Shock:

• Administer broad-spectrum IV antibiotics within the first hour of recognition. 1

Alternative Management for High-Risk Surgical Candidates

Percutaneous cholecystostomy is indicated for: 2, 3

• Critically ill patients unfit for surgery. 2
• Multiple comorbidities precluding general anesthesia. 2
• Patients not showing clinical improvement after 3-5 days of antibiotic therapy. 2

Important caveat: Cholecystostomy is inferior to cholecystectomy in terms of major complications for critically ill patients and should be viewed as a temporizing or rescue measure, not definitive therapy. 2, 3

Special Populations

Pregnant Patients:

• Early laparoscopic cholecystectomy is safe during all trimesters and associated with lower maternal-fetal complications (1.6% vs 18.4% for delayed management). 3

Elderly Patients (>65 years):

• Laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared with nonoperative management (29.3%). 3

Transplant Recipients:

• Laparoscopic cholecystectomy should be performed as soon as possible after diagnosis. 2
• Acalculous cholecystitis accounts for up to 40% of cases in this population. 2

Management of Concomitant Biliary Conditions

• For moderate/severe acute cholangitis: ERCP is the treatment of choice for biliary decompression. 2, 1
• For ERCP failures: Percutaneous transhepatic biliary drainage (PTBD) is the second-line option. 2, 1
• For suspected common bile duct stones: Obtain MRCP and consider ERCP before or during cholecystectomy. 2

Critical Pitfalls to Avoid

• Never delay surgery beyond 10 days from symptom onset—this dramatically increases complications and recurrence. 1
• Never continue antibiotics postoperatively for uncomplicated cholecystitis with adequate source control. 1, 2
• Never provide prolonged antibiotic courses (>7 days) without investigating for complications or inadequate source control. 1, 2
• Recognize that acute cholecystitis may present atypically without fever, leukocytosis, or positive Murphy's sign—maintain high clinical suspicion. 7
• Early diagnosis of gallbladder perforation and immediate surgical intervention substantially decrease morbidity (12-16%) and mortality rates. 2