From the Guidelines
The management of acute cholecystitis should prioritize early laparoscopic cholecystectomy (ELC) within 7 days of hospital admission and within 10 days of onset of symptoms, as it is associated with reduced hospital stay and complication rates, as recommended by the 2020 World Society of Emergency Surgery guidelines 1.
Initial Management
The initial treatment of acute cholecystitis involves:
- NPO status (nothing by mouth)
- Intravenous fluids for hydration
- Pain control with medications such as morphine or hydromorphone
- Antibiotic therapy, which should be started promptly with regimens such as piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours
- For patients with penicillin allergies, ciprofloxacin 400mg IV every 12 hours plus metronidazole is an alternative
Definitive Treatment
The definitive treatment for acute cholecystitis is cholecystectomy, preferably laparoscopic, which should be performed within 24-72 hours of diagnosis in most cases.
- ELC is the preferred treatment for patients who are fit to undergo surgery, as it is associated with reduced hospital stay and complication rates 1.
- For patients who are poor surgical candidates due to comorbidities, percutaneous cholecystostomy tube placement may be considered as a temporizing measure, as recommended by the 2017 WSES and SICG guidelines on acute calculous cholecystitis in elderly population 1.
- This approach allows for gallbladder decompression and drainage while the acute inflammation resolves.
Post-Procedure Care
Post-procedure care includes:
- Gradual advancement of diet as tolerated
- Pain management
- Follow-up imaging if clinically indicated
Pathophysiology
The pathophysiology of cholecystitis typically involves gallstone obstruction of the cystic duct leading to gallbladder distension, inflammation, and potential bacterial infection, which explains why both drainage and antimicrobial therapy are essential components of management. Some key points to consider:
- The evaluation of the risk for elderly patient with acute cholecystitis should include mortality rate for conservative and surgical therapeutic options, rate of gallstone-related disease relapse and the time to relapse, age-related life expectancy, and consideration of patient frailty evaluation by the use of frailty scores 1.
- The use of percutaneous cholecystostomy should be adopted only in a subset of high-risk patients to convert them into moderate risk patients, more suitable for surgery 1.
From the Research
Management Plan for Cholecystitis
- The management of cholecystitis involves a combination of surgical and non-surgical interventions, including the use of antibiotics 2, 3, 4, 5, 6.
- The Surgical Infection Society recommends against the routine use of peri-operative antibiotic agents in low-risk patients undergoing elective laparoscopic cholecystectomy, but recommends their use in patients undergoing laparoscopic cholecystectomy for acute cholecystitis 2.
- A systematic review of antibiotic treatment for acute calculous cholecystitis found that antibiotics are not indicated for the conservative management of acute cholecystitis or in patients scheduled for cholecystectomy 3.
- Updates on antibiotic regimens in acute cholecystitis suggest that early empirical antimicrobial therapy along with source control of infection is the cornerstone for successful treatment, and that the choice of antibiotic must be made considering factors such as the severity of clinical manifestations and drug resistance 4.
- A study on antibiotic use in patients with acute cholecystitis after percutaneous cholecystostomy found that patients with moderate acute cholecystitis receiving narrow-spectrum antibiotics had comparable clinical outcomes to those treated with broad-spectrum antibiotics, but that broad-spectrum antibiotics may still be necessary for patients with severe cholecystitis 5.
- The management of acute cholecystitis involves various aspects, including the type and timing of surgery, role of antibiotics, and nonoperative management, and current guidelines recommend treatment based on disease severity at presentation 6.
Antibiotic Use
- The use of antibiotics in the management of cholecystitis is controversial, with some studies suggesting that they are not necessary for uncomplicated cases 3, 6.
- However, other studies suggest that antibiotics play a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis 2, 4, 5.
- The choice of antibiotic must be made considering factors such as the severity of clinical manifestations, the onset of the infection, and drug resistance 4.
Surgical Intervention
- Early laparoscopic cholecystectomy is recommended for most patients with grade I and II diseases, and is better than delayed surgery for reducing morbidity and mortality 2, 6.
- Percutaneous cholecystostomy and novel endoscopic gallbladder drainage interventions may be used as a temporizing measure or as definitive therapy in patients who are too sick to undergo surgery 6.