Treatment of Perforated Acalculous Cholecystitis
Immediate surgical intervention with cholecystectomy (open or laparoscopic depending on patient stability) is the treatment of choice for perforated acalculous cholecystitis, as early diagnosis and prompt surgery substantially decrease morbidity and mortality rates. 1
Immediate Management Algorithm
Step 1: Resuscitation and Antibiotic Initiation
- Initiate broad-spectrum intravenous antibiotics immediately covering Gram-negative aerobes (E. coli, Klebsiella) and anaerobes (Bacteroides fragilis) 2
- In patients with sepsis or septic shock, administer antibiotics within the first hour of recognition 2
- Preferred regimens for unstable patients: piperacillin-tazobactam or cefepime plus metronidazole 2
- Begin aggressive fluid resuscitation and hemodynamic support 3
Step 2: Definitive Surgical Source Control
- Perform emergency laparotomy or laparoscopy for immediate surgical intervention 1
- Early diagnosis of gallbladder perforation and immediate surgical intervention substantially decrease morbidity and mortality rates 1
- The surgical approach should be cholecystectomy (subtotal or total depending on operative findings) 4, 3
- In cases where anatomical identification is difficult due to severe inflammation or perforation, subtotal cholecystectomy is recommended to prevent iatrogenic injuries 5
- Conversion from laparoscopic to open surgery is not a failure but a valid option when necessary for patient safety, particularly in the setting of perforation 2
Step 3: Intraoperative Considerations
- Obtain intraoperative bile cultures, especially in healthcare-associated infections or immunocompromised patients 2
- Perform thorough peritoneal lavage and drainage of any abscesses or contaminated fluid 1
- If extensive inflammation precludes safe dissection, subtotal cholecystectomy is particularly useful in cases of empyema or perforated gallbladder 5
Postoperative Antibiotic Management
For Complicated Cholecystitis with Perforation
- Continue antimicrobial therapy for 3-5 days postoperatively, adjusting duration based on clinical response 2
- Tailor the antibiotic regimen according to intraoperative bile culture results 2
- Transition from intravenous to oral antibiotics once the patient shows clinical improvement and can tolerate oral intake 2
Monitoring and Adjustments
- Reassess antibiotic dosing daily in critically ill patients, as sepsis and organ dysfunction markedly alter drug pharmacokinetics 2
- Monitor for multi-organ failure, which is common in perforated acalculous cholecystitis, and manage accordingly 4
Critical Pitfalls to Avoid
- Do not delay surgery for percutaneous drainage in patients with perforation and peritonitis - prompt surgical source control is mandatory, as ineffective control of the septic source is associated with significantly elevated mortality rates 1
- Do not rely on percutaneous cholecystostomy as definitive treatment for perforation - while cholecystostomy may be appropriate for intact acalculous cholecystitis in critically ill patients 1, perforation with peritonitis requires immediate surgical intervention 1, 3
- Do not underestimate the severity - acute acalculous cholecystitis has a high incidence of perforation and aggressive management is warranted 3, 6
- Avoid extending postoperative antibiotics beyond 3-5 days in the absence of ongoing sepsis to prevent antimicrobial resistance 2
Special Populations
Critically Ill or High-Risk Patients
- Even in critically ill patients, early surgical intervention is superior to drainage procedures when perforation is present 1
- The gallbladder should either be drained by surgical or percutaneous cholecystostomy under local anesthesia or removed, depending on the clinical situation 6
- However, in the presence of perforation with peritonitis, surgical removal is mandatory 1