Approach Considerations
Treatment of acute 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 endoscopic retrograde cholangiopancreatography (ERCP) may also be appropriate if concern exists about the presence of choledocholithiasis.
Patients admitted for acute 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 Drugs & Diseases article Acute Cholecystitis and Biliary Colic.
Initial Therapy and Antibiotic Treatment
In acute cholecystitis, the 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:
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The 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).
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Alternative regimens include a third-generation cephalosporin plus metronidazole (Flagyl, 1 g IV loading dose followed by 500 mg IV q6h).
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Bacteria that are commonly associated with cholecystitis include Escherichia coli andBacteroides fragilis, as well as Klebsiella, Enterococcus, and Pseudomonas species.
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Emesis can be treated with antiemetics and nasogastric suction.
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Because of the rapid progression of acute acalculous cholecystitis to gangrene and perforation, early recognition and intervention are required.
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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.
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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).
Conservative Treatment of Uncomplicated Cholecystitis
Outpatient treatment may be appropriate for cases of mild uncomplicated acute 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:
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Afebrile with stable vital signs
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No evidence of obstruction by laboratory values
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No evidence of common bile duct obstruction on ultrasonography
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No advanced age, underlying medical problems, pregnancy, or immunocompromised condition
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Adequate analgesia
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Reliable patient with transportation and easy access to a medical facility
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Prompt follow-up care
The following medications may be appropriate in this setting:
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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
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Antiemetics, such as oral/rectal promethazine (Phenergan) or prochlorperazine (Compazine), to control nausea and to prevent fluid and electrolyte disorders
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Analgesics, such as oral oxycodone/acetaminophen (Percocet) or hydrocodone/acetaminophen (Vicodin)
Cholecystectomy
Laparoscopic cholecystectomy is the standard of care for the surgical treatment of acute cholecystitis. Studies have indicated that early laparoscopic cholecystectomy resulted in shorter total hospital stays with no significant difference in the conversion rates or complications. [34, 35, 36, 37, 38] Zafar et al reported that the best outcomes and lowest costs were achieved when laparoscopic cholecystectomy was performed within two days of presentation of acute cholecystitis. [39]
In a retrospective meta-analysis; Huang et al analyzed the outcomes of 8960 high-risk surgical patients with acute calculous cholecystitis and concluded that laparoscopic cholecystectomy outperformed percutaneous cholecystostomy in overall morbidity, mortality, length of hospitalization, and readmission rates. [38]
The American College of Radiology (ACR) criteria state that laparoscopic cholecystectomy is the primary mode of treatment for acute cholecystitis. [1]
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: [41]
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Preoperative antibiotics should be considered only to reduce the possibility of wound infection in high-risk patients, and then limited to one preoperative dose.
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Intraoperative cholangiography may improve injury recognition and decrease the risk of bile duct injury.
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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. [42, 43]
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. [44] Immediate cholecystectomy or cholecystostomy 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 and pericholecystic stranding, which can be better observed by CT scanning compared with ultrasonography. [45]
Single-incision laparoscopic cholecystectomy appears to be safe and effective for acute cholecystitis. [37, 44] Early surgical intervention potentially reduces the risk of laparotomy conversion. [37] Note that single-incision laparoscopic cholecystectomy may be associated with an 8% rate of incisional hernia, with age (≥50 years) and body mass index (BMI) (≥30 kg/m2) as independent predictive factors. [46]
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 a pregnant woman is considered safest during the second trimester, it has been performed successfully during all trimesters.
Contraindications of laparoscopic cholecystectomy include the following:
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High risk for general anesthesia
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Morbid obesity
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Signs of gallbladder perforation, such as abscess, peritonitis, or fistula
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Giant gallstones or suspected malignancy
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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. [41]
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. [47] Results of studies suggest that most patients with acute acalculous cholecystitis can be treated with percutaneous drainage alone, [48, 49] but the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guideline describes radiographically guided percutaneous cholecystostomy as a temporizing measure until the patient can undergo cholecystectomy. [41]
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 can provide therapy by removing stones from the common bile duct.
Endoscopic ultrasound-guided transmural cholecystostomy
Studies indicate that this procedure may be safe as an initial, interim, or definitive treatment of patients with severe acute cholecystitis who are at high operative risk for immediate cholecystectomy. [50, 51]
Endoscopic gallbladder drainage
Endoscopic ultrasonographic (EUS)–guided biliary drainage procedures continue to evolve; they may be used as primary and/or second intervention, such as in the following clinical scenarios [52] :
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Biliary obstruction and incomplete drainage with prior interventions
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Inaccessible ampulla
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Previous failed bile duct cannulation during endoscopic retrograde cholangiopancreatography (ERCP)
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. [48]
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. [48]
Studies indicate that EUS-guided transmural stenting for gallbladder drainage is feasible, safe, and effective, with particularly high technical and clinical success rates with the use of plastic stents and self-expandable metal stents (SEMSs). [53] Lumen-apposing metal stents (LAMSs) show promise for having high potential in efficacy and safety.
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Acute Cholecystitis. Normal finding on hepatoiminodiacetic acid (HIDA) scan.
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Acute Cholecystitis. Abnormal finding on hepatoiminodiacetic acid (HIDA) scan.
