What is the management of acute cholecystitis?

Management of Acute Cholecystitis

Immediate Medical Stabilization

Initiate intravenous fluid resuscitation, bowel rest (NPO status), and analgesia immediately upon diagnosis, then start empiric antibiotics within the first hour if sepsis is present. 1

• Begin IV hydration, maintain NPO status, and provide pain control as soon as acute cholecystitis is confirmed 1, 2, 3
• In septic patients, early antimicrobial therapy within the first hour markedly reduces mortality 1

Antibiotic Regimens

For stable, immunocompetent patients with uncomplicated cholecystitis:

• First-line: Amoxicillin-clavulanate 2 g/0.2 g IV every 8 hours 1, 2, 3
• Alternative regimens: Ceftriaxone plus metronidazole OR ticarcillin-clavulanate 1, 2
• β-lactam allergy: Ciprofloxacin plus metronidazole, levofloxacin plus metronidazole, moxifloxacin monotherapy, eravacycline 1 mg/kg IV every 12 hours, OR tigecycline 100 mg loading dose then 50 mg IV every 12 hours 1, 3
• Risk factors for ESBL-producing organisms: Use ertapenem or tigecycline 1

For unstable, critically ill, or immunocompromised patients:

• First-line: Piperacillin-tazobactam 4 g/0.5 g IV every 6 hours (or 16 g/2 g continuous infusion) 1, 2
• Alternative: Cefepime plus metronidazole 1
• Healthcare-associated or nursing-home-acquired infections: Use piperacillin-tazobactam or a carbapenem and obtain intra-operative bile cultures 1
• Immunosuppressed patients (e.g., transplant recipients): Add enterococcal coverage to the chosen regimen 1

Important antibiotic considerations:

• Do not routinely cover enterococcus in community-acquired infections in immunocompetent patients 1
• Do not routinely cover anaerobes unless a biliary-enteric anastomosis is present 1
• Continue antibiotics until surgical intervention is performed 3

Definitive Surgical Management

Perform early laparoscopic cholecystectomy within 72 hours of diagnosis; this is the gold standard treatment that reduces hospital stay, recurrent complications, and overall morbidity compared with delayed surgery. 4, 1, 2

Optimal timing:

• Ideal window: Within 72 hours of diagnosis 1, 2, 3
• Extended acceptable window: Up to 7–10 days from symptom onset when early surgery is not immediately feasible 4, 1, 2
• If early surgery cannot be achieved: Postpone definitive cholecystectomy to at least 6 weeks after the acute episode to allow inflammation to resolve 1, 2, 3

Surgical approach:

• Laparoscopic cholecystectomy is the preferred approach for all suitable candidates, including patients >65 years of age 4, 1, 2
• Early laparoscopic cholecystectomy is as safe and effective as delayed surgery, with lower hospital costs, fewer work days lost, and greater patient satisfaction 4
• Conversion to open surgery occurs in approximately 9% of cases and should be viewed as a safety measure, not a failure 1
• Predictors of conversion to open surgery: Age >65 years, male sex, thickened gallbladder wall, diabetes mellitus, and prior upper-abdominal surgery 4, 1
• Open cholecystectomy remains a feasible option when laparoscopic approach is not possible 4

Peri-operative prophylaxis:

• Administer single-dose antibiotic prophylaxis when early laparoscopic intervention is performed 1, 2, 3

Post-operative Antibiotic Management

For uncomplicated cholecystitis with complete source control:

• No postoperative antibiotics are required; discontinue any pre-operative agents within 24 hours after surgery in immunocompetent, non-critically ill patients 4, 1, 2, 3

For complicated cholecystitis (perforation, abscess, gangrene):

• Immunocompetent patients: Limit postoperative therapy to a maximum of 4 days after adequate source control 1, 2, 3
• Immunocompromised or critically ill patients: Extend therapy up to 7 days, guided by clinical response and inflammatory markers 1, 3
• Switch from IV to oral antibiotics once the patient shows clinical improvement and can tolerate oral intake 1

Management of High-Risk or Non-Surgical Candidates

Percutaneous cholecystostomy:

• Reserve for patients with multiple comorbidities who fail to improve after 3–5 days of appropriate antibiotics 1, 2, 3
• The CHOCOLATE trial demonstrated higher mortality and major complications with percutaneous cholecystostomy compared with early laparoscopic cholecystectomy, even in high-risk groups 1
• Use cholecystostomy only as a temporizing bridge to definitive surgery; schedule interval cholecystectomy within 4–6 weeks (at least 6 weeks) once the patient stabilizes 1, 2, 5
• Percutaneous gallbladder drainage is recommended as first choice for severely physiologically deranged patients 5

Alternative drainage options:

• Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative, especially as a definitive procedure for patients not amenable to surgical management 5
• Trans-papillary gallbladder drainage is the last option, reserved only for those unfit for other techniques 5

Damage-control surgery:

• In severe hemodynamic instability with diffuse intra-abdominal infection, consider a damage-control operative strategy irrespective of patient class 1, 2
• Critically ill but surgically fit patients should undergo emergent or urgent laparoscopic cholecystectomy combined with postoperative antibiotic therapy 2

Management of Concomitant Biliary Pathology

• When choledocholithiasis or cholangitis is present, perform endoscopic retrograde cholangiopancreatography (ERCP) for biliary decompression 1, 2
• Use magnetic resonance cholangiopancreatography (MRCP) to evaluate the common bile duct when stones are suspected 1, 3

Diagnostic Imaging

• Ultrasound is the first-line imaging modality; look for pericholecystic fluid, distended gallbladder, wall edema >3 mm, gallstones, and a positive sonographic Murphy's sign (positive predictive value approximately 92–95%) 4, 1, 3
• HIDA scan offers the highest sensitivity and specificity for acute cholecystitis, though its use is limited by availability, execution time, and radiation exposure 1
• Contrast-enhanced CT is advised for complicated presentations or when the diagnosis remains uncertain 1, 3

Laboratory Predictors

• Neutrophil count is the strongest laboratory predictor of acute cholecystitis (sensitivity approximately 70%, specificity approximately 66%) 1
• Combining history, physical examination, and routine labs yields the highest diagnostic performance (positive likelihood ratio approximately 25.7) 1
• Right upper quadrant pain, fever, and leukocytosis support the diagnosis 4, 3

Critical Pitfalls to Avoid

• Do not postpone surgery to complete an extensive work-up in stable patients; concurrent imaging can be performed without delaying definitive treatment 1
• Do not extend postoperative antibiotics in uncomplicated cases with adequate source control, as this promotes antimicrobial resistance 1
• Do not rely on percutaneous drainage as definitive therapy for perforated cholecystitis with peritonitis; surgical removal is mandatory 1
• Do not withhold surgery from elderly patients solely based on age; they benefit from early cholecystectomy when medically fit 1
• Reassess antibiotic dosing daily in critically ill patients, because sepsis markedly alters pharmacokinetics 1
• Do not delay cholecystectomy beyond 10 days from symptom onset if the patient is fit for surgery 3