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Treatment of acute cholecystitisAuthorsSalam F Zakko, MD, FACPNezam H Afdhal, MD, FRCPICharles M Vollmer, Jr, MDSection EditorStanley W Ashley, MDDeputy EditorKathryn A Collins, MD, PhD, FACSDisclosuresAll topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Jan 2012. | This topic last updated: Aug 25, 2011. INTRODUCTION?—?Acute cholecystitis refers to a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation, which is usually related to gallstone disease. Complications include the development of gangrene and gallbladder perforation, which can be life-threatening.The treatment of acute cholecystitis will be reviewed here (algorithm 1). The approach to patients with gallstones, and the clinical manifestations and diagnosis of acute cholecystitis and related conditions, such as acalculous and xanthogranulomatous cholecystitis, are discussed separately. (See "Uncomplicated gallstone disease"?and "Approach to the patient with incidental gallstones"?and "Approach to the patient with suspected choledocholithiasis"?and "Pathogenesis, clinical features, and diagnosis of acute cholecystitis"?and "Acalculous cholecystitis"?and "Xanthogranulomatous cholecystitis".)SUPPORTIVE CARE?—?Patients diagnosed with acute cholecystitis should be admitted to the hospital. Patients have often been ill for days prior to seeking medical attention, making intravenous hydration and correction of any associated electrolyte disorders an important initial measure. Opioid analgesia may be required, although effective analgesia can usually be accomplished with an intramuscular injection of ketorolac?(30 to 60 mg adjusted for age and renal function), which may also favorably alter the natural history of the disease (see 'Prevention'?below). Ketorolac and butorphanol?had similar efficacy in relieving biliary colic in a small randomized controlled trial [1]. Patients should be kept fasting, and those who are vomiting should have placement of a nasogastric tube, although this is uncommon.Antibiotics?—?Although acute cholecystitis is primarily an inflammatory process, secondary infection of the gallbladder can occur as a result of cystic duct obstruction and bile stasis. In a study of 467 patients, including a control group of 42 with normal biliary trees, positive bile cultures were found in 22 percent of patients with symptomatic gallstones and 46 percent of patients with acute cholecystitis [2]. The most frequent isolates from the gallbladder or common bile duct were Escherichia coli (41 percent), Enterococcus (12 percent), Klebsiella (11 percent), and Enterobacter (9 percent).It is not clear that antibiotics are required for the treatment of uncomplicated cholecystitis. One study of 302 patients showed no difference in the development of empyema of the gallbladder or pericholecystic abscesses with the administration of antibiotics; there was, however, a lower rate of bacteremia and wound infection [3]. This is likely due to the obstruction to bile flow that interferes with achieving adequate gallbladder bile concentrations of antibiotics. However, adequate serum and tissue concentrations of antibiotics protect against septic complications such as wound infection [4]. Thus, most patients who are hospitalized for an episode of acute cholecystitis are given antibiotics [5]. Empiric antibiotic therapy should include activity against the pathogens outlined above. Empiric antibiotic therapy options and doses are provided on the table (table 1). Although cephalosporins lack activity against enterococci, this class is acceptable for empiric therapy since the pathogenicity of enterococci is relatively low and elimination of the most virulent pathogens is usually successful treatment [6]. Antibiotic therapy should subsequently be tailored to culture and susceptibility results when available.The duration of antibiotic therapy should be tailored to clinical improvement. For patients requiring prompt surgical intervention, antibiotics may be warranted for 24 to 48 hours following cholecystectomy, although longer or shorter courses may be appropriate depending on individual circumstances [7]. Patients for whom surgical intervention is initially deferred may warrant antibiotic therapy over 48 to 72 hours pending resolution of clinical signs and symptoms.TIMING OF SURGERY?—?Although there is consensus that incidentally discovered asymptomatic gallstones should not be treated [8,9], once a patient develops symptoms or complications related to gallstones (such as biliary colic or acute cholecystitis), treatment to eliminate the gallstones should be recommended, because the likelihood of subsequent symptoms or complications is high. The National Cooperative Gallstone Study, a trial of nonsurgical treatment with chenodiol for biliary tract pain, demonstrated that the risk of recurrent symptoms was approximately 70 percent during the two years following initial presentation [10]. The selection of treatment and timing of definitive therapy for acute cholecystitis depends upon the severity of symptoms and the patient's overall risk of surgery. In severe cases, when gangrene or perforation are suspected, or if patients develop signs of instability (progressive fever, intractable pain) while on supportive therapy, intervention must be considered on an emergent basis to remove the offending inflamed, gangrenous, or perforated gallbladder (picture 1). Often, cardiac arrhythmias are indicative of impending decompensation, which demands prompt intervention. (See "Overview of complications occurring in the post-anesthesia care unit", section on 'Arrhythmias'.)The aim of definitive therapy is to eliminate the precipitating cause of acute cholecystitis (ie, gallstones in the case of calculous cholecystitis) to prevent recurrent attacks. A meta-analysis of 12 randomized trials concluded that early cholecystectomy (ranging from immediate cholecystectomy to cholecystectomy within seven days of symptoms) was the preferred approach [11]. The benefit of prompt surgical intervention was also illustrated in a subsequent study of 29,818 Medicare patients with acute cholecystitis [12]. Compared to patients who underwent cholecystectomy in the initial hospitalization, patients who were discharged without surgery were more likely to require readmission (38 versus 4 percent) and had higher mortality (hazard ratio 1.56, 95% CI 1.47-1.65) over the following two years. Low-risk patients?—?The physical status scale established by the American Society of Anesthesiologists (ASA) (table 2) is commonly used to determine the risk of surgery [13]. Although previously considered to be at high risk, patients with diabetes mellitus who do not have substantial microvascular or macrovascular disease have an outcome after acute cholecystitis similar to the nondiabetic population [14].????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????Immediate cholecystectomy is preferred for patients who are at low-risk (ASA classes I and II). Several studies have indicated that cholecystectomy performed for low surgical risk patients during the initial hospitalization can reduce morbidity and costs [15-18]. In a randomized trial of 100 patients with acute cholecystitis, there were two deaths and four cases of peritonitis in patients who were awaiting delayed surgery [17]. Early surgery is also easier to perform as local inflammation increases 72 hours past the initial onset of symptoms making dissection less precise, increasing the severity of surgical complications, and open conversion more likely.Cholecystectomy can most often be accomplished laparoscopically. Laparoscopic cholecystectomy eliminates the need to cut the rectus abdominis muscle, reduces postoperative pain, and significantly shortens hospital length of stay and convalescence. However, conversion to open cholecystectomy should be performed if the surgeon fails to make adequate and safe progress in the dissection. Surgery for acute cholecystitis can be complicated by common bile duct injuries or excessive blood loss [19,20]. Injury and blood loss can be avoided by performing a subtotal cholecystectomy, leaving the dome of the gallbladder adherent to the liver fossa in situ, and achieving control of the cystic duct at the level of the neck of the gallbladder. Biliary leaks following this approach are possible, but generally can be managed conservatively. Overall, open cholecystectomy and laparoscopic cholecystectomy still have significant mortality rates (around 5 and 1 percent, respectively) and these rates are highest in the setting of acute cholecystitis. (See "Laparoscopic cholecystectomy: Techniques"?and "Complications of laparoscopic cholecystectomy"?and "Repair of common bile duct injuries".)High-risk patients?—?Patients who are in ASA classes III, IV, or V have a surgical mortality ranging from 5 to 27 percent, and are considered high-risk for cholecystectomy [13]. This category generally includes patients with severe chronic illnesses, such as cardiovascular or pulmonary disease, or advanced malignancy. In addition, otherwise low-risk patients who present with sepsis should also be considered high-risk until their physiologic profile can be improved. Gallbladder drainage?—?High-risk patients, or patients who present late in the course of their disease process (beyond three to five days), who continue to have severe symptoms and show no appreciable improvement despite one to two days of medical management require further intervention: Gallbladder drainage by percutaneous cholecystostomy in conjunction with antibiotics is the initial treatment of choice for such patients [21-24]. The goal of cholecystostomy is to drain purulent material from the obstructed gallbladder. The technical success of percutaneous cholecystostomy ranges from 82 to 100 percent in various series [21-24]. Tube decompression of the gallbladder allows for resolution of edema which often “opens” up the obstructed cystic duct. Success in resolving the acute cholecystitis is slightly less. Failure is usually related to ineffective drainage due to thick sludge or pus. We generally irrigate the gallbladder contents manually with normal saline through the catheter. If irrigation is ineffective, the percutaneous pigtail catheter can be replaced with a larger one to achieve more effective irrigation. Complications are infrequent but may include bleeding, catheter blockage and dislodgement, and failure to resolve the acute cholecystitis [22,24]. Endoscopic transpapillary gallbladder drainage has also been reported in patients with acute cholecystitis in whom percutaneous approaches are contraindicated or anatomically impossible [25,26]. A limitation of the technique is that it can be technically challenging to place a guidewire and drainage tube into the gallbladder. In addition, this procedure carries all the inherent and occasionally serious complications of endoscopic retrograde cholangiography. (See "Overview of indications for and complications of ERCP and endoscopic biliary sphincterotomy".)Surgery?—?When the cholecystitis has resolved, patients who are surgical candidates should undergo cholecystectomy [27]. Emergent operative approaches may be required, even in the face of high-risk physiology, as there are certain occasions when the aforementioned less-invasive techniques are not technically feasible. Furthermore, the risk of surgery may be less than the burden of continued systemic effects of cholecystitis on these already compromised patients. Surgery may also be required when the patient does not improve following percutaneous drainage, which suggests that the gallbladder has already progressed to gangrene. While total or subtotal cholecystectomy are both options, those patients who are particularly unstable will benefit from open cholecystostomy tube drainage achieved through a limited laparotomy. This can be performed at the bedside in the ICU setting if necessary. Nonsurgical treatment?—?Patients who stabilize but continue to be at high risk for surgery can be considered for gallstone dissolution therapy or percutaneous gallstone extraction with or without mechanical lithotripsy. (See "Nonsurgical treatment of gallstone disease".)PROGNOSIS?—?The overall mortality of a single episode of acute cholecystitis is approximately 3 percent. However, the risk in a given patient depends upon the patient's health and surgical risk [22]. The mortality is less than 1 percent in young, otherwise healthy patients, and approaches 10 percent in high-risk patients or in those in whom complications have developed.PREVENTION?—?In addition to eliminating the cause of acute cholecystitis (usually gallstones), there is considerable interest in preventing the progression of biliary colic to acute cholecystitis. Increasing experience suggests that use of nonsteroidal antiinflammatory drugs (NSAIDs) can produce effective analgesia for biliary colic, and may favorably alter its natural history [28-30]. The latter benefit may reflect the role of prostaglandins in the development of acute cholecystitis. (See "Pathogenesis, clinical features, and diagnosis of acute cholecystitis", section on 'Pathogenesis'.)The efficacy of NSAIDs was evaluated in a trial of 53 patients with cholelithiasis and biliary colic who were randomized to receive a single intramuscular injection of diclofenac?(75 mg) or placebo [28]. Treatment with diclofenac was significantly more effective in relieving pain and substantially reduced the rate of progression to acute cholecystitis (15 versus 42 percent). Another double-blind study of 37 patients who had 40 separate attacks of biliary colic demonstrated that indomethacin?was also effective for relieving pain [31]. We use ketorolac?(30 to 60 mg adjusted for age and renal function given in a single intramuscular dose) for patients who present to the emergency department with biliary colic. Treatment usually relieves symptoms within 20 to 30 minutes. Patients are then prescribed ibuprofen?400 mg orally to be taken during subsequent attacks, until definitive treatment can be accomplished.SUMMARY AND RECOMMENDATIONSAcute cholecystitis refers to a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation, which is usually related to gallstone disease. Complications include the development of gangrene and gallbladder perforation, which can be life-threatening. (See 'Introduction'?above.) Patients diagnosed with acute cholecystitis require hospital admission for intravenous hydration, correction of electrolyte disorders, and pain control. Patients should be kept fasting and those who are vomiting may need placement of a nasogastric tube. (See 'Supportive care'?above.) We suggest patients who are hospitalized for an episode of acute cholecystitis be given antibiotics (Grade 2C). (See 'Antibiotics'?above.) The selection of treatment and timing of definitive therapy for acute cholecystitis depends upon the severity of symptoms and the patient's overall risk of surgery. (See 'Timing of surgery'?above.) We recommend that patients who are surgical candidates undergo cholecystectomy during their initial hospitalization (Grade 1A). Prompt surgical intervention decreases hospital readmission rates and mortality. (See 'Low-risk patients'?above.) High-risk patients, or patients who present late in their disease course, who continue to have severe symptoms and show no appreciable improvement despite one to two days of medical management require further intervention with gallbladder drainage. (See 'Gallbladder drainage'?above.) When the cholecystitis has resolved, patients who are surgical candidates should undergo cholecystectomy. (See 'Surgery'?above.) Surgery may also be required when the patient does not improve following percutaneous drainage, which suggests that the gallbladder has already progressed to gangrene. While total or subtotal cholecystectomy are options, those patients who are particularly unstable will benefit from open cholecystostomy tube drainage achieved through a limited laparotomy. (See 'Surgery'?above.). Patients who stabilize but continue to be at high risk for surgery can be considered for gallstone dissolution therapy or percutaneous gallstone extraction with or without mechanical lithotripsy. (See "Nonsurgical treatment of gallstone disease".)Use of UpToDate is subject to the Subscription and License Agreement. REFERENCESOlsen JC, McGrath NA, Schwarz DG, et al. A double-blind randomized clinical trial evaluating the analgesic efficacy of ketorolac versus butorphanol for patients with suspected biliary colic in the emergency department. Acad Emerg Med 2008; 15:718. Csendes A, Burdiles P, Maluenda F, et al. Simultaneous bacteriologic assessment of bile from gallbladder and common bile duct in control subjects and patients with gallstones and common duct stones. Arch Surg 1996; 131:389. Kune GA, Burdon JG. Are antibiotics necessary in acute cholecystitis? Med J Aust 1975; 2:627. J?rvinen H, Renkonen OV, Palmu A. Antibiotics in acute cholecystitis. Ann Clin Res 1978; 10:247. 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