Management of acute cholecystitis

Conservative management:
Initially acute cholecystitis is managed conservatively with bed-rest, gut-rest, analgesia with NSAIDs and opiates, anti-emetics, IV fluids and antibiotics:

• broad-spectrum antibiotics are used to cover the most common organisms found in the biliary tract
  • biliary tract infections are generally coliforms (1) - if not penicillin allergic then initially iv co-amoxiclav and then oral co-amoxiclav (1)
• is the mainstay of treatment in frail and elderly patients who have only a single attack, or mild recurrent episodes
• after initial treatment patients may either undergo an elective laparoscopic cholecystectomy, or an early cholecystectomy during their emergency admission (2,3)

Surgical management:
Cholecystectomy has been the treatment of choice for acute cholecystitis:

• laparoscopic cholecystectomy
  • laparoscopic cholecystectomy is considered the treatment of choice for most patients
    • the common practice is to treat the patient conservatively and to discharge after resolution of the acute attack and arrange for an elective cholecystectomy several weeks later, when the inflammation should have completely settled
    • a Cochrane systematic review has revealed that
      • early surgery has a lower complication or conversion rate than delayed cholecystectomy
      • in delayed cholecystectomies, a 30% re-admission rate with gallstone-related complications is seen before the planned operation (2,3)
    • laparoscopic cholecystectomy within 72 hours of admission is thought to reduce complications and hospital stay (4)
      
    • Note: the term “early” has been variably defined as anywhere from 24 hours to 7 days after either the onset of symptoms or the time of diagnosis (2)
• open cholecystectomy
  • performed less frequently nowadays
  • carried out when laparoscopic technique fails due to adhesions, inflammation, bleeding, inability to define anatomy and suspected bile duct injury (3)
    
    
• urgent cholecystectomy is indicated in the following instances:
  • fever, marked leukocytosis, or diffuse abdominal tenderness indicates possible necrosis, empyema, or rupture and surgery within 12 to 24 hours is indicated
  • patients with diabetes
  • elderly and immunocompromised patients (4).

Percutaneous cholecystostomy:

• considered in an emergency situation in patients who are not suitable for cholecystectomy because of their general medical condition
• cholecystectomy may be considered later with improvement of patients condition

TG18 guideline recommendations for management of acute cholecystitis:

• when acute cholecystitis is suspected, diagnostic assessment is made using TG13 diagnostic criteria every 6–12 h
• abdominal ultrasound is carried out, followed by hepatobiliary iminodiacetic acid (HIDA) scan or CT scan if needed to make the diagnosis
• severity is repeatedly assessed using severity assessment criteria: at diagnosis, within 24 h after diagnosis, and during the time zone of 24–48 h, and evaluate for surgical risk
• taking into consideration the need for cholecystectomy, as soon as a diagnosis has been made, initiate treatment with replacement of sufficient fluid, electrolyte compensation, fasting, and administration of intravenous analgesics and full dose antimicrobial agents
• appropriate treatment in accordance with the severity grade
  • Grade I (mild) acute cholecystitis
    • Laparoscopic cholecystectomy (Lap-C) at an early stage within 7 days (within 72 h is better) of onset of symptoms is recommended
    • if conservative treatment is selected and no response to the initial treatment is observed within 24 h, reconsider early Lap-C if still within 7 days since onset of symptoms or biliary tract drainage
  • Grade II (moderate) acute cholecystitis
    • urgent/early Lap-C if patient performance status is good and advanced Lap-C technique is available
    • urgent/early biliary drainage or delayed/elective Lap-C if patient’s condition is poor
  • Grade III (severe) acute cholecystitis
    • urgent/early biliary drainage
    • early Lap-C at an advanced center if no negative predictive factors, organ system failure and patient has good status
• blood culture and/or bile culture is performed for Grade II (moderate) and III (severe) patients (5)
• consider transfer to advanced facilities if urgent/emergency Lap-C, biliary drainage, and intensive care not available

References:

1. NHS Foundation Trust. Acute cholecystitis https://www.nhs.uk/conditions/acute-cholecystitis/ (accessed 27 January 2022)
2. Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med. 2008;358(26):2804-11
3. Dawson J. Acute cholecystitis. GPonline 2009
4. Oymaci E.  Determination of optimal operation time for the management of acute cholecystitis: a clinical trial. Prz Gastroenterol. 2014;9(3):147-52
5. Okamoto K et al. TG13 management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013;20(1):55-59