Cholecystitis Treatment & Management

  • Author: Alan A Bloom, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Jun 30, 2011
 

Approach Considerations

Treatment of cholecystitis depends on the severity of the condition and the presence or absence of complications. Uncomplicated cases can often be treated on an outpatient basis; complicated cases may necessitate a surgical approach. In patients who are unstable, percutaneous transhepatic cholecystostomy drainage may be appropriate. Antibiotics may be given to manage infection. Definitive therapy involves cholecystectomy or placement of a drainage device; therefore, consultation with a surgeon is warranted. Consultation with a gastroenterologist for consideration of ERCP may also be appropriate if concern exists of choledocholithiasis.

Patients admitted for cholecystitis should receive nothing by mouth because of expectant surgery. However, in uncomplicated cholecystitis, a liquid or low-fat diet may be appropriate until the time of surgery.

For more information, see the Medscape Reference article Imaging in Cholecystitis and Biliary Colic.

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Initial Therapy and Antibiotic Treatment

For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, correction of electrolyte abnormalities, analgesia, and intravenous antibiotics. For mild cases of acute cholecystitis, antibiotic therapy with a single broad-spectrum antibiotic is adequate. Some options include the following:

  • The current Sanford guide recommendations include piperacillin/tazobactam (Zosyn, 3.375 g IV q6h or 4.5 g IV q8h), ampicillin/sulbactam (Unasyn, 3 g IV q6h), or meropenem (Merrem, 1 g IV q8h). In severe life-threatening cases, the Sanford Guide recommends imipenem/cilastatin (Primaxin, 500 mg IV q6h).
  • Alternative regimens include a third-generation cephalosporin plus metronidazole (Flagyl, 1 g IV loading dose followed by 500 mg IV q6h).
  • Bacteria that are commonly associated with cholecystitis include Escherichia coli and Bacteroides fragilis and Klebsiella, Enterococcus, and Pseudomonas species.
  • Emesis can be treated with antiemetics and nasogastric suction.
  • Because of the rapid progression of acute acalculous cholecystitis to gangrene and perforation, early recognition and intervention are required.
  • Supportive medical care should include restoration of hemodynamic stability and antibiotic coverage for gram-negative enteric flora and anaerobes if biliary tract infection is suspected.
  • Daily stimulation of gallbladder contraction with intravenous cholecystokinin (CCK) has been shown by some to effectively prevent the formation of gallbladder sludge in patients receiving total parenteral nutrition (TPN).
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Conservative Treatment of Uncomplicated Cholecystitis

Outpatient treatment may be appropriate for cases of uncomplicated cholecystitis. If a patient can be treated as an outpatient, discharge with antibiotics, appropriate analgesics, and definitive follow-up care. Criteria for outpatient treatment include the following:

  • Afebrile with stable vital signs
  • No evidence of obstruction by laboratory values
  • No evidence of common bile duct obstruction on ultrasonography
  • No underlying medical problems, advanced age, pregnancy, or immunocompromised condition
  • Adequate analgesia
  • Reliable patient with transportation and easy access to a medical facility
  • Prompt follow-up care

The following medications may be appropriate in this setting:

  • Prophylactic antibiotic coverage with levofloxacin (Levaquin, 500 mg PO qd) and metronidazole (500 mg PO bid), which should provide coverage against the most common organisms
  • Antiemetics, such as oral/rectal promethazine (Phenergan) or prochlorperazine (Compazine), to control nausea and to prevent fluid and electrolyte disorders
  • Analgesics, such as oral oxycodone/acetaminophen (Percocet) or oxycodone/acetaminophen (Vicodin)
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Cholecystectomy

Laparoscopic cholecystectomy is the standard of care for the surgical treatment of cholecystitis. Studies have indicated that early laparoscopic cholecystectomy resulted in shorter total hospital stays with no significant difference in conversion rates or complications.[27, 28, 29] The ACR 2010 criteria state that laparoscopic cholecystectomy is the primary mode of treatment for acute cholecystitis.[15]

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) issued guidelines for the clinical application of laparoscopic biliary tract surgery in 2010. The guidelines include detailed recommendations for making the decision to operate, performing the procedure, and managing postoperative care, with the patient's safety always the primary consideration. Recommendations are as follows:[30]

  • Preoperative antibiotics should be considered only to reduce the possibility of wound infection in high-risk patients, and then limited to one preoperative dose.
  • Intraoperative cholangiography may improve injury recognition and decrease the risk of bile duct injury.
  • If bile duct injury occurs, the patient should be referred to an experienced hepatobiliary specialist before any repair is undertaken, unless the primary surgeon has experience with biliary reconstruction.

Wilson et al used decision tree analytic modeling to compare the cost-effectiveness and quality-adjusted life years (QALYs) of early laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC) and found that, on average, ELC is less expensive and results in better quality of life (+0.05 QALYs per patient) than DLC.[31]

Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients treated by surgeons with adequate experience in laparoscopic cholecystectomy.[32] Immediate cholecystectomy or cholecystotomy is usually reserved for complicated cases in which the patient has gangrene or perforation.

One study suggests that when CT scanning is performed as long as 72 hours prior to surgery, it may better detect acute gangrenous cholecystitis. Acute gangrenous cholecystitis was significantly correlated with perfusion defect of the gallbladder wall, pericholecystic stranding, and no-gallstone condition, which can be better observed through CT scanning when compared with ultrasonography.[33]

For elective laparoscopic cholecystectomy, the rate of conversion from a laparoscopic procedure to an open surgical procedure is approximately 5%. The conversion rate for emergency cholecystectomy where perforation or gangrene is present may be as high as 30%.

Although laparoscopic cholecystectomy performed in pregnant women is considered safest during the second trimester, it has been performed successfully during all trimesters.

Contraindications to laparoscopic cholecystectomy include the following:

  • High risk for general anesthesia
  • Morbid obesity
  • Signs of gallbladder perforation, such as abscess, peritonitis, or fistula
  • Giant gallstones or suspected malignancy
  • End-stage liver disease with portal hypertension and severe coagulopathy

The 2010 SAGES guideline adds to these contraindications septic shock from cholangitis, acute pancreatitis, lack of equipment, lack of surgical expertise, and previous abdominal surgery that impedes the procedure.[30]

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Percutaneous Drainage

For patients at high surgical risk, placement of a sonographically guided, percutaneous, transhepatic cholecystostomy drainage tube coupled with the administration of antibiotics may provide definitive therapy.[34] Results of studies suggest that most patients with acute acalculous cholecystitis can be treated with percutaneous drainage alone,[35] but the SAGES guideline describes radiographically guided percutaneous cholecystostomy as a temporizing measure until the patient can undergo cholecystectomy.[30]

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Endoscopic Treatment

Endoscopy may be used for therapeutic purposes, as well as for diagnosis.

Endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) allows visualization of the anatomy and may be therapeutic by removing stones from the common bile duct.

Endoscopic ultrasound-guided transmural cholecystostomy

Studies indicate that this procedure may be safe as initial, interim, or definitive treatment of patients with severe acute cholecystitis who are at high operative risk for immediate cholecystectomy.[36]

Endoscopic gallbladder drainage

Mutignani et al, in a study of the efficacy of endoscopic gallbladder drainage as a treatment for acute cholecystitis in 35 patients with the condition and with no residual common bile duct obstruction, found that endoscopic gallbladder drainage was technically successful in 29 patients and, after a median period of 3 days, clinically successful in 24 of them.[35]

Four patients died within 3 days after the procedure as a result of septic complications, while a fifth patient accidentally removed a nasocholecystic drain 24 hours after the operation. At follow-up (on 21 patients, after a median period of 17 months), the investigators found that 4 patients had suffered a relapse of either acute cholecystitis (2 patients) or biliary pain (2 patients). Mutignani et al concluded that endoscopic gallbladder drainage appears to be an effective, but temporary, means of resolving acute cholecystitis.[35]

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Contributor Information and Disclosures
Author

Alan A Bloom, MD  Associate Clinical Professor of Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Gastroenterology, Veterans Affairs Hospital, Bronx

Alan A Bloom, MD is a member of the following medical societies: American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, New York Academy of Medicine, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Coauthor(s)

Zahir Amin, MD, MBBS, MRCP, FRCR  Consulting Staff, Department of Imaging, University College Hospital, UK

Zahir Amin, MD, MBBS, MRCP, FRCR is a member of the following medical societies: British Institute of Radiology, British Medical Association, and Royal College of Radiologists

Disclosure: Nothing to disclose.

BS Anand, MD  Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Clinton S Beverly, MD  Clinical Assistant Professor, Department of Surgery, Mercer University School of Medicine

Clinton S Beverly, MD is a member of the following medical societies: American College of Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Burt Cagir, MD, FACS  Assistant Professor of Surgery, State University of New York Upstate Medical University; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, and Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Hemalatha Chandramohan, MBBS  Registrar, General Practice, West Yorkshire, UK

Hemalatha Chandramohan, MBBS is a member of the following medical societies: Royal College of Obstetricians and Gynaecologists

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Jack A Di Palma, MD  Director, Division of Gastroenterology, Professor, Department of Internal Medicine, University of South Alabama College of Medicine

Jack A Di Palma, MD is a member of the following medical societies: American College of Gastroenterology and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Arnold C Friedman, MD, FACR  Professor, Department of Radiology, University of Florida Health Science Center; Chief, Department of Radiology, Shands-Jacksonville Hospital

Arnold C Friedman, MD, FACR is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America

Disclosure: Nothing to disclose.

Spencer B Gay, MD  Professor of Radiology, Department of Radiology and Medical Imaging, University of Virginia School of Medicine

Disclosure: Nothing to disclose.

Don Gladden, DO  Staff Physician, Department of Emergency Medicine, Seton Medical Center Williamson

Don Gladden, DO is a member of the following medical societies: American College of Emergency Physicians

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Michael A Grosso, MD  Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

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John L Haddad, MD  Clinical Associate Professor, Department of Radiology, Weill Medical College of Cornell University; Director of Body MRI, Department of Radiology, Methodist Hospital in Houston

John L Haddad, MD is a member of the following medical societies: American College of Radiology, American Medical Association, and Radiological Society of North America

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John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

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Eugene Hardin, MD, FAAEM, FACEP  Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

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Ravi Devidas Kadasne, MBBS, MD  Specialist in Radiology, Emirates International Hospital, UAE

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Samuel M Keim, MD  Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine

Samuel M Keim, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine

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Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR  Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UK

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies: American Association for the Advancement of Science, American Institute of Ultrasound in Medicine, British Medical Association, British Society of Interventional Radiology, Royal College of Physicians, Royal College of Physicians and Surgeons of the United States, Royal College of Radiologists, and Royal College of Surgeons of England

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Lalam Radhesh Krishna, MBBS  Specialist Registrar, Department of Radiology, North Manchester General Hospital, UK

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J David Lane, MD, RT  Chief, CMH Vascular and Interventional Radiology, Wisconsin Radiology Specialists, SC; Former Section Chief, Assistant Professor, Vascular and Interventional Radiology, Walter Reed Army Medical Center, Uniformed Services University of the Health Sciences

J David Lane, MD, RT is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Radiological Society of North America, and Society of Interventional Radiology

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Nick Lomis, MD  QI Coordinator, Diagnostic Radiology Service, Assistant Chief, Interventional Radiology and Diagnostic Radiology, Walter Reed Army Medical Center

Nick Lomis, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America

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Alexandre F Migala, DO  Staff Physician, Department of Emergency Medicine, Denton Regional Medical Center

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H Leon Pachter, MD, FACS  Chair, George David Stewart Professor, Department of Surgery, New York University Medical Center

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Manish Parikh, MD  Assistant Professor of Surgery, Department of Surgery, New York University School of Medicine; Attending Surgeon, Director Laparoscopic and Bariatric Surgery, Bellevue Hospital

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Tufail Ahmed Patankar, MBBS, PhD, MSc, FRCR  Consulting Interventional Neuroradiologist, Department of Neuroradiology, Leeds General Infirmary, UK

Tufail Ahmed Patankar, MBBS, PhD, MSc, FRCR is a member of the following medical societies: British Society of Neuroradiologists and Royal College of Radiologists

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Tushar Patel, MB, ChB  Professor of Medicine, Ohio State University Medical Center

Tushar Patel, MB, ChB is a member of the following medical societies: American Association for the Study of Liver Diseases and American Gastroenterological Association

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Marco G Patti, MD  Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine

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Prospere Remy, MD  Assistant Professor of Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Internal Medicine, Bronx-Lebanon Hospital Center

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Rahul Sharma, MD, MBA, FACEP  Assistant Professor, Weill Medical College of Cornell University; Assistant Director for Operations, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center

Rahul Sharma, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians

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Peter A D Steel, MA, MBBS  Staff Physician, Department of Emergency Medicine, Joan and Sanford I Weill Medical College of Cornell and Columbia University College of Physicians and Surgeons, New York Presbyterian Hospitals

Peter A D Steel, MA, MBBS is a member of the following medical societies: American College of Emergency Physicians, British Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

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Alan BR Thomson, MD  Professor of Medicine, Division of Gastroenterology, University of Alberta, Canada

Alan BR Thomson, MD is a member of the following medical societies: Alberta Medical Association, American College of Gastroenterology, American Gastroenterological Association, Canadian Association of Gastroenterology, Canadian Medical Association, College of Physicians and Surgeons of Alberta, and Royal College of Physicians and Surgeons of Canada

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Jeffery Wolff, DO  Consulting Staff, Department of Gastroenterology, Brooke Army Medical Center; Staff Gastroenterologist, Landstuhl Regional Medical Center

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Specialty Editor Board

Anil Minocha, MD, FACP, FACG  Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center; Clinical Professor, University of Mississippi School of Pharmacy

Anil Minocha, MD, FACP, FACG is a member of the following medical societies: American Academy of Clinical Toxicology, American Association for the Study of Liver Diseases, American College of Forensic Examiners, American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy

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Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

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John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

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Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

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Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Walter E Pofahl, MD, Amber A Guth, MD, FACS, Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, and David Sherlock, MBBS, FRCS, to the development and writing of the source articles.

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Cholecystitis. Normal finding on hepatoiminodiacetic acid (HIDA) scan.
Cholecystitis. Abnormal finding on hepatoiminodiacetic acid (HIDA) scan.
 
 
 
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