Cholecystitis Guidelines

Updated: May 20, 2021
  • Author: Alan A Bloom, MD; Chief Editor: BS Anand, MD  more...
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Guidelines

WSES Guidelines on the Diagnosis and Treatment of Acute Calculus Cholecystitis (2020)

Clinical practice guidelines on the diagnosis and treatment of acute calculus cholecystitis (ACC) were updated in November 2020 by the World Society of Emergency Surgery (WSES). [54]

Diagnosis

The suggested combination for diagnosis is a detailed history, complete clinical examination, laboratory testing, and imaging investigations. It is recommended to not rely on a single diagnostic test or clinical or laboratory finding, as none has sufficient diagnostic power to establish or exclude the diagnosis of ACC. The best combination of diagnostic investigations is not known.

The preferred initial imaging technique is abdominal ultrasonography (US). It is cost-effective, noninvasive, widely available, and accurate.

Other suggested imaging studies in select patients may include hepatobiliary iminodiacetic acid scanning, which has the highest sensitivity and specificity for ACC diagnosis compared with other imaging modalities. The accuracy of MRI is comparable to abdominal US. The accuracy of CT scanning for the diagnosis of ACC is considered poor.

Surgical Treatment

The recommended first-line treatment for ACC is laparoscopic cholecystectomy.

Laparoscopic cholecystectomy should be avoided in patients with septic shock or absolute anesthesiology contraindications.

Laparoscopic cholecystectomy is suggested to be safe and feasible in patients who have Child-Pugh A or B cirrhosis, those of advanced age (>80 years), or women who are pregnant.

If there is difficulty with anatomic identification of structures during cholecystectomy, the recommended procedure is laparoscopic or open subtotal cholecystectomy.

Conversion from laparoscopic to open cholecystectomy is recommended in patients with severe local inflammation, adhesions, bleeding from the cystohepatic (Calot) triangle, or suspected injury to the bile duct.

Timing of Cholecystectomy in ACC

If adequate surgical expertise is available, the recommended timing for early laparoscopic cholecystectomy is that it should be performed as soon as possible, within 7 days from admission to the hospital and within 10 days from symptom onset.

If early laparoscopic cholecystectomy cannot be performed in the recommended time parameters, delayed laparoscopic cholecystectomy should be performed after 6 weeks from first clinical presentation.

Alternative Treatments and Gall Bladder Drainage in Patients Not Suitable for Surgery

For patients who refuse surgery or those who are not suitable to undergo surgery, nonoperative management with best medical therapy (ie, antibiotics, observation) is suggested.

Alternative treatment options can be considered in patients in whom nonoperative management fails, those who still refuse surgery, and those who are not suitable for surgery.

Gallbladder drainage is recommended in patients with ACC who are not suitable for surgery; this procedure converts a septic patient with ACC into a nonseptic patient.

Delayed laparoscopic cholecystectomy can be offered to patients after perioperative risk is reduced; this decreases the re-admission rate for ACC relapse or gallstone-related disease.

In patients with ACC who are not suitable for surgery, alternatives to percutaneous transhepatic gallbladder drainage include endoscopic transpapillary gallbladder drainage or US-guided transmural gallbladder drainage; both are considered safe and effective alternatives if performed at a high-volume center by a skilled endoscopist.

In this select group of patients, endoscopic transmural US-guided gallbladder drainage with lumen-apposing self-expandable metal stents is preferred over endoscopic transpapillary gallbladder drainage.

Antibiotics in ACC

The routine use of postoperative antibiotics is not recommended in uncomplicated ACC when the focus of infection is controlled by cholecystectomy.

In complicated ACC, it is recommended that an antimicrobial regimen is prescribed; it should be based on the presumed pathogens involved and major resistance patterns.

In the case of complicated ACC with a high risk for antimicrobial resistance, it is recommended that the antibiotic regimen be targeted based on the results of a microbiological analysis, which ensures adequate antimicrobial coverage.

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WSES Guidelines on Acute Calculous Cholecystitis in the Elderly (2017)

The guidelines on acute calculous cholecystitis (ACC) in the elderly were released on March 4, 2019, by the World Society of Emergency Surgery (WSES) and the Italian Society of Geriatric Surgery (SICG). [55]

Diagnostic Testing

In elderly patients, no single investigation is capable of establishing or excluding ACC without further testing. A combination of symptoms, signs, and laboratory tests results may have better diagnostic accuracy.

Abdominal ultrasonography (US) is the preferred initial imaging technique for elderly patients clinically suspected of having acute cholecystitis.

Data on the diagnostic accuracy of computed tomography (CT) are scarce. The accuracy of magnetic resonance imaging (MRI) may be comparable to that of abdominal US, but the data are insufficient to support this view. Hepatobiliary iminodiacetic acid (HIDA) scanning has the highest sensitivity and specificity, but scarce availability, long execution time, and radiation exposure limit its use.

Combining clinical, laboratory, and imaging investigations should be recommended, though the best combination is not yet known.

No high-quality studies on specific diagnostic findings of ACC in the elderly are available.

Pros vs Cons of Surgical Treatment

Old age (>65 years), by itself, is not a contraindication for cholecystectomy to treat ACC.

Cholecystectomy is the preferred treatment for ACC even in elderly patients.

Evaluation of risk for elderly ACC patients should include the following:

  • Mortality for conservative and surgical therapeutic options

  • Rate of gallstone-related disease relapse and time to relapse

  • Age-related life expectancy

  • Patient frailty; consider use of frailty scores for assessment

  • Specific risk (for individual patient or particular procedure); consider use of surgical clinical scores

Optimal Timing and Choice of Surgical Technique

A laparoscopic approach should always be attempted first, except in the case of absolute anesthetic contraindications or septic shock.

Laparoscopic cholecystectomy is safe and feasible in elderly patients, associated with a low complication rate and a shorter hospital stay.

Laparoscopic or open subtotal cholecystectomy is a valid option for advanced inflammation, gangrenous gallbladder, and "difficult gallbladder."

Conversion to open surgery may be predicted by fever, leukocytosis, elevated serum bilirubin, and extensive upper abdominal surgery. It should be considered in the setting of local severe inflammation, adhesions, bleeding in the Calot triangle, or suspected bile duct injury.

Laparoscopic cholecystectomy should be performed as soon as possible but can be performed up to 10 days after the onset of symptoms.

Percutaneous Cholecystostomy in Patients Unsuitable for Surgery

Percutaneous cholecystostomy can be considered in the treatment of ACC patients deemed unfit for surgery (>65 years, American Society of Anesthesiologists [ASA] class 3 or 4, performance status 3 to 4, septic shock).

When medical therapy has failed, percutaneous cholecystostomy should be considered as a bridge to cholecystectomy in acutely ill (high-risk) elderly patients deemed unfit for surgery to render them more suitable for surgery.

Percutaneous transhepatic cholecystostomy is the preferred method of performing percutaneous cholecystostomy.

The percutaneous cholecystostomy catheter should be removed 4-6 weeks after placement if a cholangiogram performed 2-3 weeks after cholecystostomy demonstrated biliary tree patency.

Management of Associated Biliary Tree Stones

Elevation of liver biochemical enzymes and/or bilirubin levels is not sufficient to identify patients with choledocholithiasis; further diagnostic tests are needed.

Visualization of common bile duct (CBD) stones on abdominal US is a very strong predictor of choledocholithiasis. Indirect signs of stone presence (eg, increased CBD diameter) are not sufficient to identify patients with choledocholithiasis; further diagnostic tests are needed.

Liver biochemical tests and abdominal US should be performed in all patients to assess the risk for CBD stones. CBD stone risk should be stratified according to a classification modified from American Society of Gastrointestinal Endoscopy (ASGE) and Society of American Gastrointestinal Endoscopic Surgeons (SAGES) guidelines.

Elderly patients at moderate risk for choledocholithiasis should be evaluated with preoperative magnetic resonance cholangiopancreatography (MRCP), endoscopic US, intraoperative cholangiography, or laparoscopic US, depending on local expertise and availability.

Elderly patients at high risk for choledocholithiasis should undergo preoperative endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, or laparoscopic US, depending on local expertise and availability.

CBD stones may be removed preoperatively, intraoperatively, or postoperatively in accordance with local expertise and availability.

Choice of Antibiotic Regimen

Elderly patients with uncomplicated cholecystitis can be treated without postoperative antibiotics when the focus of infection is controlled by cholecystectomy.

In elderly patients with complicated acute cholecystitis, broad-spectrum antibiotic regimens are recommended; adequate empiric therapy significantly affects outcomes in critical elderly patients.

Microbiologic analysis is helpful for designing targeted therapeutic strategies for individual patients.

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