What is the appropriate management of acute cholecystitis?

Management of Acute Cholecystitis

Early laparoscopic cholecystectomy performed within 72 hours of diagnosis is the definitive treatment for acute cholecystitis and should be undertaken immediately in all operable patients. 1, 2

Initial Medical Stabilization

Before surgery, initiate the following supportive measures immediately upon diagnosis:

• Intravenous fluid resuscitation to correct dehydration and maintain hemodynamic stability 3, 4
• NPO status (nothing by mouth) to rest the gallbladder and prevent further stimulation 3, 4
• Analgesia for pain control 3, 4
• Empiric antibiotic therapy started within the first hour if sepsis is present, as early antimicrobial therapy markedly reduces mortality 3

Diagnostic Confirmation

Ultrasound is the investigation of choice for confirming acute cholecystitis, with key findings including: 1, 3, 5

• Pericholecystic fluid around the gallbladder
• Distended gallbladder with wall edema >3 mm
• Gallstones, particularly if impacted in the cystic duct
• Positive sonographic Murphy's sign (positive predictive value 92-95%)

CT with IV contrast should be obtained when complications are suspected (perforation, abscess, gangrene) or the diagnosis remains uncertain. 1, 3

MRCP is indicated when choledocholithiasis or cholangitis is suspected based on abnormal liver function tests or dilated bile ducts. 1, 2

Antibiotic Selection

Uncomplicated Cholecystitis in Stable, Immunocompetent Patients

First-line: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours 1, 2, 3

Alternatives:

• Ceftriaxone plus metronidazole 2, 3
• Ticarcillin/clavulanate 2

If β-lactam allergy:

• Ciprofloxacin plus metronidazole 3, 5
• Levofloxacin plus metronidazole 3, 5
• Moxifloxacin monotherapy 3

If risk factors for ESBL-producing organisms (recent hospitalization, nursing home residence, prior antibiotic exposure):

• Ertapenem 1g IV every 24 hours 1, 3, 5
• Eravacycline 1 mg/kg IV every 12 hours 1
• Tigecycline 100 mg loading dose, then 50 mg IV every 12 hours 1, 3

Complicated Cholecystitis or Critically Ill/Immunocompromised Patients

First-line: Piperacillin/tazobactam 4g/0.5g IV every 6 hours (or 16g/2g continuous infusion after 6g/0.75g loading dose) 1, 2, 3, 5

Alternatives:

• Cefepime plus metronidazole 3, 5
• Ertapenem 1g IV every 24 hours 1, 5

If septic shock:

• Meropenem 1g IV every 6 hours by extended infusion or continuous infusion 1
• Doripenem 500 mg IV every 8 hours by extended infusion 1
• Imipenem/cilastatin 500 mg IV every 6 hours by extended infusion 1
• Eravacycline 1 mg/kg IV every 12 hours 1

Important caveats:

• Do not routinely cover enterococcus in community-acquired infections in immunocompetent patients; its pathogenic role is unclear 3, 5
• Add enterococcal coverage only in immunosuppressed patients (e.g., transplant recipients) 3, 5
• Do not routinely cover anaerobes unless a biliary-enteric anastomosis is present 2, 3

Surgical Timing and Approach

Optimal Timing Window

Perform laparoscopic cholecystectomy within 72 hours of diagnosis. 1, 2, 3, 5 This narrow window is associated with:

• Shorter hospital stay 1, 5
• Reduced recurrent biliary complications 5
• Lower hospital costs 1, 5
• Fewer work days lost (approximately 9 days sooner return to work) 1, 5
• Greater patient satisfaction 1, 5

Extended acceptable window: Surgery may be performed up to 7-10 days from symptom onset if the 72-hour window is missed. 1, 2, 5

Critical timing pitfall: If early surgery cannot be achieved within 7-10 days, delay cholecystectomy to at least 6 weeks after the acute episode to allow inflammation to resolve. 2, 5, 6 Intermediate-timing surgery (7 days to 6 weeks) is associated with higher rates of serious adverse events and should be avoided. 5

Surgical Technique

Laparoscopic cholecystectomy is the preferred approach for all suitable candidates, including patients >65 years of age. 1, 2, 5 It offers:

• Shorter hospital stay compared to open surgery 1, 4
• Less postoperative pain 4
• Earlier return to productivity 4

Risk factors predicting conversion to open surgery (occurs in approximately 9% of cases): 1, 2, 5

• Age >65 years
• Male gender
• Thickened gallbladder wall
• Diabetes mellitus
• Previous upper abdominal surgery

Conversion to open surgery is a safety measure, not a failure. 1, 2, 5 When anatomical identification is difficult and bile duct injury risk is high, perform subtotal cholecystectomy (laparoscopic or open) rather than forcing total cholecystectomy. 5

Perioperative Antibiotic Prophylaxis

Single-dose antibiotic prophylaxis is administered when early laparoscopic intervention is performed. 1, 2

Postoperative Antibiotic Duration

Uncomplicated Cholecystitis with Complete Source Control

No postoperative antibiotics are required. 1, 2, 3, 5 Discontinue any preoperative antibiotics within 24 hours after surgery. 2, 3, 5 This applies to immunocompetent, non-critically ill patients with adequate source control.

Complicated Cholecystitis (Perforation, Abscess, Gangrene)

Immunocompetent patients: Limit postoperative antibiotic therapy to a maximum of 4 days after adequate source control. 1, 2, 3, 5

Immunocompromised or critically ill patients: Extend therapy up to 7 days, guided by clinical response and inflammatory markers (CRP, WBC). 1, 2, 3, 5

Transition to oral antibiotics once the patient shows clinical improvement and can tolerate oral intake. 3, 5

Patients with ongoing signs of infection beyond 7 days warrant diagnostic investigation for undrained collections or other complications. 1

Management of High-Risk or Non-Surgical Candidates

Percutaneous Cholecystostomy

Reserve percutaneous cholecystostomy only for patients with multiple comorbidities who fail to improve after 3-5 days of appropriate antibiotics or those with prohibitive physiological derangement. 2, 3, 7

Critical evidence: The CHOCOLATE randomized trial demonstrated that early laparoscopic cholecystectomy results in significantly lower mortality and fewer major complications compared to percutaneous cholecystostomy, even in critically ill patients. 2, 3, 5 Mortality rates with cholecystostomy can reach 30-50% if used as definitive therapy. 3

If cholecystostomy is performed:

• Use it only as a temporizing bridge to surgery, not definitive therapy 2, 3, 5, 7
• Continue antibiotics for 4 days after drainage 1
• Schedule interval cholecystectomy within 4-6 weeks once the patient stabilizes 3, 5, 7

Endoscopic Gallbladder Drainage

Endoscopic drainage (cholecystoduodenostomy or cholecystogastrostomy) is suggested as a second-line alternative, especially as a definitive procedure for patients not amenable to surgical management. 7

Trans-papillary gallbladder drainage is the last option, reserved only for those unfit for other techniques. 7

Important: When metal stents are used, remove them within 4 weeks to prevent food impaction and recurrent cholecystitis. 5

Management of Concomitant Biliary Pathology

When choledocholithiasis or cholangitis is present:

• Perform ERCP for biliary decompression before or concurrent with cholecystectomy 1, 2, 3
• Use MRCP to evaluate the common bile duct when stones are suspected 1, 2
• Biliary drainage plus antibiotic therapy for 4 days in immunocompetent patients, up to 7 days in immunocompromised or critically ill patients 1

Special Populations

Elderly Patients

Do not withhold surgery from elderly patients solely based on age; they benefit from early cholecystectomy when medically fit. 2, 3, 5 Age >65 years is a risk factor for conversion to open surgery but not a contraindication to laparoscopic approach. 1, 2, 5

Cirrhotic Patients

Laparoscopic cholecystectomy remains feasible and safe in patients with liver cirrhosis, although the risk of conversion to open procedure is higher. 3 Hepatomegaly alone should not delay definitive cholecystectomy unless it reflects decompensated cirrhosis. 3

Transplant Recipients

Transplanted patients should undergo cholecystectomy as soon as possible after diagnosis, with laparoscopic approach preferred whenever feasible. 5 Add specific enterococcal coverage to the antibiotic regimen. 3, 5

Management of Gallbladder Perforation

Early diagnosis and immediate surgical intervention markedly decrease morbidity and mortality rates. 1, 3 Gallbladder perforation occurs in 2-11% of acute cholecystitis cases, with mortality as high as 12-16%. 1

Perforation types:

• Type I (acute/free perforation): Generalized peritonitis requiring immediate laparotomy or laparoscopy 1
• Type II (subacute): Pericholecystic abscess with localized peritonitis 1
• Type III (chronic): Cholecystoenteric fistula 1

Critical pitfall: Percutaneous drainage must not be used as definitive therapy for perforated cholecystitis with peritonitis; surgical removal of the gallbladder is mandatory. 3, 5 Delaying surgery to attempt percutaneous drainage significantly increases mortality. 3, 5

Conservative Management Outcomes

Conservative management with fluids, analgesia, and antibiotics may be considered for mildly symptomatic patients without peritonitis, but long-term outcomes are poor: 5, 8

• Approximately 30% develop recurrent gallstone-related complications 5
• 60% eventually require cholecystectomy 5
• Higher rates of complications, mortality, and longer hospitalization time compared to early surgery 8

Critical Pitfalls to Avoid

• Do not postpone surgery to complete extensive work-up in stable patients; concurrent imaging can address both gallbladder and other issues 3, 5
• Do not extend postoperative antibiotics in uncomplicated cases with adequate source control, as this promotes antimicrobial resistance 3, 5
• Do not use intermediate-timing surgery (7 days to 6 weeks), which has higher adverse event rates 5
• Reassess antibiotic dosing daily in critically ill patients, as sepsis markedly alters pharmacokinetics 3, 5
• Do not rely on percutaneous drainage as definitive therapy; it is inferior to cholecystectomy even in high-risk patients 2, 3, 5