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 complications and hospital stay, according to the most recent guidelines 1.
Treatment Overview
The treatment of cholecystitis depends on the severity of the disease, but often requires hospitalization. Initial management includes:
- Fasting
- IV fluids
- Pain control with medications like morphine or hydromorphone
- Antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1g IV daily plus metronidazole 500mg IV every 8 hours for 3-5 days
Definitive Treatment
Definitive treatment is usually cholecystectomy (surgical removal of the gallbladder), preferably performed within 24-72 hours of diagnosis for acute cases.
- Early surgery reduces complications and hospital stay
- For patients who cannot undergo immediate surgery due to medical conditions, percutaneous cholecystostomy (gallbladder drainage) may be performed
Prevention Strategies
Prevention strategies include:
- Maintaining a healthy weight
- Eating regular meals
- Following a low-fat diet
Diagnosis
Diagnosis typically involves:
- Physical examination
- Blood tests showing elevated white blood cell count and liver enzymes
- Imaging studies like ultrasound or CT scan to confirm gallbladder inflammation and identify gallstones
Complications
Cholecystitis can be life-threatening if untreated, as it may lead to:
- Gallbladder perforation
- Sepsis
- Pancreatitis According to the most recent guidelines, early treatment with laparoscopic cholecystectomy is recommended for uncomplicated cholecystitis, with one-shot prophylaxis if early intervention and no post-operative antibiotics 1. For complicated cholecystitis, laparoscopic cholecystectomy with open cholecystectomy as an alternative is recommended, along with antibiotic therapy for 4 days in immunocompetent patients and up to 7 days in immunocompromised or critically ill patients 1.
From the Research
Definition and Treatment of Cholecystitis
- Cholecystitis is a common serious complication of gallstones, with a reported mortality rate of approximately 3% 2.
- The current standard of care for acute cholecystitis is early laparoscopic cholecystectomy with appropriate administration of fluid, electrolyte, and antibiotics 2.
- The optimal timeframe to perform early laparoscopic cholecystectomy (ELC) is within 72 hours from diagnosis, with a possible extension of up to 7-10 days from symptom onset 3.
Antibiotic Use in Cholecystitis
- The use of peri-operative antibiotic agents is recommended for patients undergoing laparoscopic cholecystectomy for acute cholecystitis 4.
- However, routine use of peri-operative antibiotic agents is not recommended in low-risk patients undergoing elective laparoscopic cholecystectomy 4.
- In patients with moderate acute cholecystitis after percutaneous cholecystostomy, narrow-spectrum antibiotics have comparable clinical outcomes to broad-spectrum antibiotics 5.
- A systematic review found that antibiotics are not indicated for the conservative management of acute calculous cholecystitis or in patients scheduled for cholecystectomy 6.
Special Considerations
- In critically ill patients who are unfit for surgery, rescue treatments such as percutaneous or endoscopic gallbladder drainage (GBD) may be required 3.
- A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients 3.
- In elderly patients or patients with significant comorbidity, operational risks may still be high, making cholecystectomy inappropriate, and alternative treatments such as gallstone removal using the percutaneous tract or endoscopy may be considered 2.