From the Guidelines
Laparoscopic cholecystectomy is the recommended treatment for acute cholecystitis, and it should be performed within 7 days of hospital admission and within 10 days of onset of symptoms, as it has been shown to be superior to delayed laparoscopic cholecystectomy or intermediate laparoscopic cholecystectomy in terms of reducing hospital stay and complication rates 1. The treatment of acute cholecystitis typically involves initial medical management followed by surgical intervention. Initial treatment includes bowel rest, intravenous fluids for hydration, pain control with medications, and broad-spectrum antibiotics such as piperacillin-tazobactam or a combination of ceftriaxone plus metronidazole, which target common biliary pathogens including E. coli, Klebsiella, and anaerobes. Some key points to consider in the treatment of acute cholecystitis include:
- The use of early laparoscopic cholecystectomy, which has been shown to be safe and effective even in high-risk patients 1
- The importance of performing laparoscopic cholecystectomy within a reasonable time frame, as delayed surgery can lead to increased complication rates and longer hospital stays
- The role of percutaneous cholecystostomy tube placement as a temporary measure for patients who are poor surgical candidates due to severe comorbidities or critical illness
- The need for supportive care, including antiemetics, correction of electrolyte abnormalities, and monitoring for complications such as perforation, gangrene, or emphysematous cholecystitis
- The fact that the inflammation in acute cholecystitis is typically caused by gallstone obstruction of the cystic duct, leading to bile stasis, increased pressure, and secondary bacterial infection, which explains why both gallstone removal and antimicrobial therapy are essential components of treatment. In terms of specific treatment recommendations, laparoscopic cholecystectomy is the preferred treatment for patients with acute cholecystitis, and it should be performed by experienced surgeons 1. If early laparoscopic cholecystectomy cannot be performed, delayed laparoscopic cholecystectomy may be considered, although the evidence suggests that this approach may be associated with higher complication rates and longer hospital stays compared to early laparoscopic cholecystectomy 1. Overall, the treatment of acute cholecystitis requires a multidisciplinary approach that takes into account the patient's overall health status, the severity of the disease, and the availability of surgical expertise. The goal of treatment should be to reduce morbidity, mortality, and improve quality of life, and laparoscopic cholecystectomy has been shown to be an effective and safe treatment option for patients with acute cholecystitis 1.
From the Research
Treatment Options for Acute Cholecystitis
- Early laparoscopic cholecystectomy (ELC) is considered the best treatment for acute cholecystitis, with the optimal timeframe for performing ELC being within 72 hours from diagnosis 2.
- In patients who are not eligible for ELC, surgery may be delayed at least 6 weeks after clinical presentation 2.
- For critically ill patients who are unfit for surgery, rescue treatments such as percutaneous or endoscopic gallbladder drainage (GBD) may be required 2.
Antibiotic Therapy
- Antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis 3.
- The choice of antibiotic must be made considering factors such as the severity of clinical manifestations, the onset of infection, and drug resistance 3.
- The Surgical Infection Society recommends the use of peri-operative antibiotic agents for patients undergoing laparoscopic cholecystectomy for acute cholecystitis, but against routine use in low-risk patients undergoing elective laparoscopic cholecystectomy 4.
Special Populations
- In pregnant women, early laparoscopic cholecystectomy is recommended during all trimesters, as it is associated with a lower risk of maternal-fetal complications compared to delayed operative management 5, 6.
- In elderly patients, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up compared to nonoperative management 6.
- For patients with acalculous acute cholecystitis, percutaneous cholecystostomy tube placement should be reserved for those who are severely ill at the time of diagnosis, while others should undergo laparoscopic cholecystectomy 6.