Treatment

Empiric antibiotic therapy and cholecystectomy are the mainstays of treatment for acute cholecystitis after initial supportive therapy.

Initial management

• Screen patients for signs of sepsis or shock.

• Start empiric antibiotic therapy for acute biliary infection.

• Provide initial supportive therapy for acute biliary disease.

• Consult general surgery to determine:

  • Surgical risk.

  • Definitive management based on severity grading of acute cholecystitis and risk of complications .

• Identify and treat concurrent choledocholithiasis

The initial procedure and duration of antibiotic therapy depend on severity grading of acute cholecystitis, patient's individual surgical risk, and presence of complications.

• Laparoscopic cholecystectomy

  • Preferred approach if expertise is available

  • Perform as soon as possible, unless operative and anesthesia risks outweigh the benefits of urgent surgery.

• Gallbladder drainage procedures (e.g., percutaneous cholecystostomy) typically performed as a temporizing measure for:

  • Unstable or clinically deteriorating patients: e.g., grade II–III acute cholecystitis

  • Frail patients or those at high risk of surgical complications

Perform preoperative or postoperative stone extraction in patients with concurrent choledocholithiasis.

• Low surgical risk

  • Early laparoscopic cholecystectomy

  • Postoperative antibiotics not required

• High surgical risk

  • Early intervention

    • Early laparoscopic cholecystectomy

    • Discontinue antibiotics 24 hours after surgery.

  • OR conservative approach

    • Continue antibiotics until symptomatic improvement

    • Arrange interval cholecystectomy

• Improvement with initial management

  • Low surgical risk

    • Early laparoscopic cholecystectomy

    • Discontinue antibiotics 24 hours after surgery.

  • High surgical risk :

    • Continue antibiotics until symptomatic improvement.

    • Arrange interval cholecystectomy

• Deterioration despite initial management

  • Urgent gallbladder drainage followed by interval cholecystectomy

  • Continue antibiotics for a total of 7 days

• Low surgical risk

  • Early laparoscopic cholecystectomy if there is an adequate response to initial supportive care

  • Continue antibiotics for 4–7 days after surgery.

• High surgical risk

  • Urgent gallbladder drainage, followed by:

    • Interval cholecystectomy

    • OR observation

  • Continue antibiotics for a total of 7 days.

• Indication: gold standard of treatment for acute calculous cholecystitis [22]

• Timing: depends on surgical and anesthesia risks, disease severity, and symptom duration

  • Early laparoscopic cholecystectomy: performed within 10 days of symptom onset; preferably within the initial 24–72 hours [22][24]

    • Indication: symptom duration of ≤ 10 days in patients with low surgical and anesthesia risk(s) [22]

    • Contraindications

      • High surgical or anesthesia risks

      • Symptom duration > 10 days

  • Interval laparoscopic cholecystectomy (delayed lap. chole)

    • Performed 45 days after resolution of symptoms [22]

    • Indications

      • High surgical or anesthesia risk

      • Symptom duration > 10 days

• Indication: temporizing, minimally invasive measures in high surgical-risk patients not responding to conservative management

• Contraindication: uncontrolled bleeding diathesis

• Options

  • Percutaneous cholecystostomy: image-guided placement of a catheter (cholecystostomy tube) into the gallbladder under local anesthesia through the abdominal wall to provide biliary drainage

  • Endoscopic gallbladder stenting: may be preferred over percutaneous cholecystostomy if endoscopy operator expertise is available as it is less invasive