What is the recommended management of acute cholecystitis in a typical adult patient?

Treatment of Acute Cholecystitis

Perform early laparoscopic cholecystectomy within 72 hours of diagnosis (or up to 7-10 days from symptom onset) combined with immediate antibiotic therapy—this approach reduces hospital stay, recurrent complications, and overall morbidity compared to delayed surgery. 1, 2, 3

Initial Medical Management

Immediate Stabilization

• Start intravenous fluids, bowel rest (NPO status), and analgesia immediately upon diagnosis 1, 3
• Initiate empiric antibiotic therapy within the first hour if sepsis is present, as early antimicrobial therapy markedly reduces mortality 2

Antibiotic Selection for Stable, Immunocompetent Patients

• First-line: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours 4, 1, 3
• Alternatives: Ceftriaxone + metronidazole OR ticarcillin/clavulanate 4
• If β-lactam allergy: Ciprofloxacin + metronidazole OR levofloxacin + metronidazole OR moxifloxacin (monotherapy) 4
• If ESBL risk factors present: Ertapenem OR tigecycline 4, 2

Antibiotic Selection for Unstable/Critically Ill Patients

• First-line: Piperacillin-tazobactam 4g/0.5g IV every 6 hours (or 16g/2g continuous infusion) 4, 1, 2
• Alternative: Cefepime + metronidazole 4
• These agents provide excellent biliary penetration and coverage of resistant pathogens 2

Special Antibiotic Considerations

• Healthcare-associated or nursing home-acquired infections: Use piperacillin-tazobactam or carbapenems due to higher multidrug-resistant organism prevalence; obtain intraoperative bile cultures 2
• Immunosuppressed patients (transplant recipients): Add specific enterococcal coverage to your chosen regimen 2
• Do NOT routinely cover enterococcus in community-acquired infections in immunocompetent patients—its pathogenic role is unclear 2
• Do NOT routinely cover anaerobes unless a biliary-enteric anastomosis is present 2

Definitive Surgical Management

Timing of Surgery

• Optimal window: Within 72 hours of diagnosis 1, 2, 3
• Acceptable extended window: Up to 7-10 days from symptom onset 1, 2, 3
• If early surgery cannot be performed within this timeframe: Delay cholecystectomy to at least 6 weeks after clinical presentation 2, 3, 5

Surgical Approach

• Laparoscopic cholecystectomy is the preferred approach for all suitable candidates, including elderly patients (age >65 years is NOT a contraindication) 4, 1, 2
• Conversion to open surgery occurs in approximately 9% of cases and is NOT a failure but an appropriate safety measure when anatomic identification is difficult 2, 6
• Risk factors predicting conversion to open: Age >65 years, male gender, thickened gallbladder wall, diabetes mellitus, previous upper abdominal surgery 2

Surgical Prophylaxis

• Give single-shot antibiotic prophylaxis if early intervention is performed 3

Postoperative Antibiotic Duration

Uncomplicated Cholecystitis with Complete Source Control

• No postoperative antibiotics are required—discontinue within 24 hours after surgery 1, 2, 3
• This applies to immunocompetent, non-critically ill patients 1, 3

Complicated Cholecystitis (perforation, abscess, gangrenous changes)

• Immunocompetent patients: Maximum 4 days of antibiotic therapy after adequate source control 1, 2, 3
• Immunocompromised or critically ill patients: Up to 7 days based on clinical response and inflammatory markers 1, 2, 3
• Transition from IV to oral antibiotics once clinical improvement occurs and oral intake is tolerated 2

Management of High-Risk or Unsuitable Surgical Candidates

Percutaneous Cholecystostomy

• Reserve percutaneous cholecystostomy ONLY for patients with multiple comorbidities who do not improve after 3-5 days of appropriate antibiotic therapy 1, 3
• The CHOCOLATE trial demonstrated that percutaneous cholecystostomy is associated with significantly higher mortality and more major complications compared to early laparoscopic cholecystectomy, even in high-risk patients 2
• Use cholecystostomy only as a temporizing bridge to surgery in patients too unstable for immediate operation—NOT as definitive therapy 2
• If used as a bridge, perform interval cholecystectomy within 4-6 weeks once the patient stabilizes 2

Damage Control in Severe Sepsis

• In severe hemodynamic instability with diffuse intra-abdominal infection, consider a damage-control surgical procedure irrespective of patient class 1

Management of Concomitant Biliary Pathology

• When choledocholithiasis or cholangitis is present: Perform ERCP for biliary decompression 1, 2
• Consider magnetic resonance cholangiopancreatography (MRCP) for evaluating the common bile duct when stones are suspected 1, 3

Diagnostic Considerations

Imaging

• Ultrasound is the preferred initial imaging technique: Look for pericholecystic fluid, distended gallbladder, wall edema (>3mm), gallstones, and sonographic Murphy's sign (92-95% positive predictive value) 4, 2, 3
• HIDA scan has the highest sensitivity and specificity for acute cholecystitis, though limited by availability, long execution time, and radiation exposure 4
• CT with IV contrast is recommended for complicated cases or unclear diagnosis 3

Laboratory Findings

• Neutrophil count is the strongest laboratory predictor (sensitivity ~70%, specificity ~66%) 2
• Combined assessment of history, physical examination, and routine labs yields the highest diagnostic performance (positive likelihood ratio ~25.7) 2
• No single investigation has sufficient diagnostic power alone—combination of symptoms, signs, and laboratory tests provides better accuracy 4

Critical Pitfalls to Avoid

• Do NOT delay surgery to complete extensive workup in stable patients—concurrent imaging can address both gallbladder and other issues 2
• Do NOT extend postoperative antibiotics in uncomplicated cases with adequate source control, as this promotes antimicrobial resistance 2
• Do NOT use percutaneous drainage as definitive therapy for perforated cholecystitis with peritonitis—surgical removal is mandatory 2
• Do NOT withhold surgery from elderly patients based solely on age—they benefit from early cholecystectomy when fit for surgery 2, 3
• Reassess antibiotic dosing daily in critically ill patients, as sepsis markedly alters drug pharmacokinetics 2