Acute cholecystitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

mild (grade I): stable without signs of perforation/gangrene

1st line – supportive care

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1st line –

supportive care

Mild (grade I) disease is defined as acute cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder; responds to initial medical treatment.[35]

When a diagnosis of acute cholecystitis is suspected, medical treatment, including nothing by mouth, intravenous fluids, antibiotics, and analgesia, together with close monitoring of blood pressure, pulse, and urinary output, should be initiated, with a view to carrying out early laparoscopic cholecystectomy.

Medical treatment may be sufficient, and urgent surgery may not be required if timely access to laparoscopic expertise is limited.[52]

Patients should receive adequate analgesia (e.g., acetaminophen and/or an opioid). Nonsteroidal anti-inflammatory drugs (NSAIDs) may benefit patients with biliary colic but must be used with caution particularly in patients with a likelihood of early surgery, due to increased risk of gastrointestinal bleeding.[29][87] In practice, NSAIDs are usually avoided in patients with confirmed cholecystitis.

Plus – empiric intravenous antibiotic

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Plus –

empiric intravenous antibiotic

Treatment recommended for ALL patients in selected patient group

Antibiotics are recommended if infection is suspected on the basis of laboratory and clinical findings.[80]

Options include a suitable cephalosporin (e.g., ceftriaxone), a carbapenem (e.g., ertapenem), or a fluoroquinolone (e.g., ciprofloxacin, levofloxacin, moxifloxacin). Fluoroquinolones are only recommended if the susceptibility of cultured isolates is known or for patients with beta‐lactam allergies.[80] The 2018 Tokyo guideline also recommends ampicillin/sulbactam, a penicillin with a beta-lactamase inhibitor, as an alternative option (if the resistance rate is <20%); however this is not recommended in North American guidelines due to widespread resistance.[80][82]

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[81] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug informaton source for more information on suitability, contraindications, and precautions.

Patients are observed and treated with antibiotics, with a view to proceeding to cholecystectomy. However, supportive care alone may be sufficient preceding delayed elective cholecystectomy.[83]

Antibiotic therapy can be discontinued within 24 hours of cholecystectomy in grade I disease. However, if perforation, emphysematous changes, or necrosis of the gallbladder are noted during cholecystectomy, antibiotic therapy duration of 4-7 days is recommended.[80]

Intravenous antibiotics may be switched to a suitable oral antibiotic regimen once the patient can tolerate oral feeding.[80][85]

Examples of suitable antibiotic regimens are given here; however, consult your local guidelines for guidance on antibiotic selection.

Primary options

ceftriaxone: 1-2 g intravenously every 12-24 hours

ertapenem: 1 g intravenously every 24 hours

Secondary options

ciprofloxacin: 400 mg intravenously every 8-12 hours

levofloxacin: 500-750 mg intravenously every 24 hours

moxifloxacin: 400 mg intravenously every 24 hours

Consider – anaerobic antibiotic cover

Consider – early laparoscopic cholecystectomy

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Consider –

early laparoscopic cholecystectomy

Treatment recommended for SOME patients in selected patient group

For patients with mild cholecystitis, the Tokyo guidelines state that early laparoscopic cholecystectomy (ELC, performed within 72 hours of symptom onset) is the preferred treatment.[34] It has a clear benefit compared with delayed cholecystectomy (>6 weeks after index admission) in terms of complication rate, cost, hospital stay, quality of life, and patient satisfaction.[57][60][61][62][63][64]

There is no advantage to delaying cholecystectomy for acute cholecystitis on the basis of outcomes.[90] Early surgery, even when performed in patients >72 hours from symptom onset is safe and associated with less overall morbidity, shorter total hospital stay and duration of antibiotic therapy, and reduced cost compared with delayed cholecystectomy (performed ≥6 weeks after the onset of symptoms).[35][36][58][59] [ ]

Early cholecystectomy is a feasible treatment for older patients, with one systematic review finding perioperative morbidity of 24% and perioperative mortality of 3.5% in patients ages ≥70 years.[54] Older patients should be carefully selected; perioperative complications and mortality may be attributable to comorbid conditions and/or reduced physiologic reserves rather than the surgical procedure.[54][55]

Conversion to the open procedure may be required if there is significant inflammation, difficulty delineating the anatomy, or significant bleeding.[65][66] ELC has not been shown to significantly affect conversion rate to open cholecystectomy.[60][61] Conversion rates were assessed in one retrospective review of 493 patients with acute cholecystitis from 2010-2013. Severity classification according to the 2013 Tokyo guidelines was found to be the most powerful predictive factor for conversion.[67] Male sex, diabetes mellitus, and total bilirubin level were also found to be independent risk factors for conversion to open surgery.[67] The operating surgeon should be experienced in carrying out laparoscopic cholecystectomies, have access to intraoperative cholangiography should it be needed, and have a low threshold for conversion to open surgery if required.

Patients with Child-Turcotte-Pugh grade A or B liver cirrhosis who undergo ELC have fewer overall postoperative complications, a shorter hospital stay, and quicker resumption of a normal diet than those who undergo the open procedure.[68]

Consider – percutaneous cholecystostomy

Consider – endoscopic transpapillary gallbladder drainage or endoscopic ultrasound-guided gallbladder drainage

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Consider –

endoscopic transpapillary gallbladder drainage or endoscopic ultrasound-guided gallbladder drainage

Treatment recommended for SOME patients in selected patient group

Percutaneous transhepatic gallbladder drainage is considered the first-line alternative to surgical intervention in surgically high-risk patients with acute cholecystitis. However, endoscopic transpapillary gallbladder drainage or endoscopic ultrasound (EUS)-guided gallbladder drainage can also be considered in some resource settings.[95][96][97] More recent systematic reviews and meta-analyses have shown EUS-guided gallbladder drainage to be associated with better clinical outcomes than percutaneous cholecystostomy and endoscopic transpapillary gallbladder drainage in high-risk surgical patients.[95][98][99] The American Gastroenterological Association suggests the use of EUS gallbladder drainage in high-risk surgical patients with acute cholecystitis, removal of percutaneous cholecystostomy drains in patients who are not candidates for cholecystectomy by allowing internal drainage, and drainage of malignant biliary obstruction in select patients.[95] The American Society for Gastrointestinal Endoscopy also recommends EUS-guided gallbladder drainage for selected patients who are not candidates for cholecystectomy.[100]

moderate (grade II): stable with signs of perforation/gangrene

1st line – supportive care

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1st line –

supportive care

Moderate (grade II) disease is defined as acute cholecystitis associated with any one of the following: elevated white blood cell count (>18,000/microliter), palpable tender mass in the right upper abdominal quadrant, duration of complaints >72 hours, and marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis).[35]

Patients should receive adequate analgesia (e.g., acetaminophen and/or an opioid). Nonsteroidal anti-inflammatory drugs (NSAIDs) may benefit patients with biliary colic but must be used with caution particularly in patients with a likelihood of early surgery, due to increased risk of gastrointestinal bleeding.[87][29] In practice, NSAIDs are usually avoided in patients with confirmed cholecystitis.

Plus – empiric intravenous antibiotic

Back

Plus –

empiric intravenous antibiotic

Treatment recommended for ALL patients in selected patient group

Antibiotics are recommended if infection is suspected on the basis of laboratory and clinical findings.[80]

Empiric intravenous antibiotic therapy should be started before the infecting isolates are identified. Antibiotic choice largely depends on local susceptibility patterns.[80] Local susceptibility patterns vary geographically and over time. The likelihood of resistance of the organism will also vary by whether the infection was hospital- or community-acquired, although there may be resistant organisms in the community.[80] Choice of antibiotic regimen follows the same principles as for grade I disease. Antibiotic therapy can be discontinued within 24 hours after cholecystectomy is performed in grade II disease. However, if perforation, emphysematous changes, or necrosis of the gallbladder are noted during cholecystectomy, antibiotic therapy duration of 4-7 days is recommended.[80]

Intravenous antibiotics may be switched to a suitable oral antibiotic regimen once the patient can tolerate oral feeding.[80][85]

Antibiotic options include a penicillin with a beta-lactamase inhibitor (e.g., piperacillin/tazobactam), a suitable cephalosporin (e.g., ceftriaxone), a carbapenem (e.g., ertapenem), or a fluoroquinolone (e.g., ciprofloxacin, levofloxacin, moxifloxacin). Fluoroquinolones are only recommended if the susceptibility of cultured isolates is known or for patients with beta‐lactam allergies.[80]

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[81] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

Examples of suitable antibiotic regimens are given here; however, consult your local guidelines for guidance on antibiotic selection.

Primary options

piperacillin/tazobactam: 3.375 to 4.5 g intravenously every 6 hours

ceftriaxone: 1-2 g intravenously every 12-24 hours

ertapenem: 1 g intravenously every 24 hours

Secondary options

ciprofloxacin: 400 mg intravenously every 8-12 hours

levofloxacin: 500-750 mg intravenously every 24 hours

moxifloxacin: 400 mg intravenously every 24 hours

Consider – anaerobic antibiotic cover

Plus – early cholecystectomy or cholecystostomy with delayed cholecystectomy

Back

Plus –

early cholecystectomy or cholecystostomy with delayed cholecystectomy

Treatment recommended for ALL patients in selected patient group

Moderate-grade cholecystitis usually does not respond to initial medical treatment. Patients who do not improve under conservative treatment are referred to either surgery or percutaneous cholecystostomy.

Early laparoscopic cholecystectomy (ELC, within 72 hours of symptom onset) could be indicated if advanced laparoscopic techniques and skills are available.[34][56][57][86]

In patients with moderately severe cholecystitis, where there is no organ dysfunction but there is extensive disease in the gallbladder (which can confer difficulty in safely carrying out a cholecystectomy), ELC or open cholecystectomy is preferred but should be carried out only by a highly experienced surgeon. If operative conditions make anatomic identification difficult, ELC should be promptly terminated by conversion to open cholecystostomy. Interval cholecystectomy can then be performed in 6-8 weeks.[34]

Percutaneous cholecystostomy should be considered for poor surgical candidates (e.g., medically not suitable for surgery). Patients treated with cholecystostomy tube can be discharged with their tube in place after the inflammatory process has resolved clinically. These patients should subsequently undergo a cholangiogram through the cholecystostomy tube (6-8 weeks) to see whether the cystic duct is open.[35][36] If the duct is open and the patient is a good surgical candidate, they should be referred for cholecystectomy.

severe (grade III): suspected gangrene/perforation or evidence of organ dysfunction

1st line – intensive care admission and supportive care

Plus – empiric intravenous antibiotic

Back

Plus –

empiric intravenous antibiotic

Treatment recommended for ALL patients in selected patient group

Antibiotics are recommended if infection is suspected on the basis of laboratory and clinical findings.[80]

Antibiotic options include a penicillin with a beta-lactamase inhibitor (e.g., piperacillin/tazobactam), a suitable cephalosporin (e.g., cefepime), a carbapenem (e.g., ertapenem, meropenem), or a monobactam (e.g., aztreonam).[80]

Once the source of infection is controlled, the recommended duration of antibiotic treatment is 4-7 days. If bacteremia with gram‐positive cocci (e.g., Enterococcus species, Streptococcus species) is present, a duration of at least 2 weeks is recommended.[80] If residual stones or obstruction of the bile tract are present, treatment should be continued until these anatomic problems are resolved. If liver abscess is present, treatment should be continued until clinical, biochemic, and radiologic follow‐up demonstrates complete resolution of the abscess.[80]

Intravenous antibiotics may be switched to a suitable oral antibiotic regimen once the patient can tolerate oral feeding.[80][85]

Examples of suitable antibiotic regimens are given here; however, consult your local guidelines for guidance on antibiotic selection.

Primary options

piperacillin/tazobactam: 3.375 to 4.5 g intravenously every 6 hours

cefepime: 2 g intravenously every 8-12 hours

ertapenem: 1 g intravenously every 24 hours

meropenem: 1 g intravenously every 8 hours

aztreonam: 1-2 g intravenously every 6-12 hours

Plus – Enterococcus antibiotic cover

Consider – anaerobic antibiotic cover

Plus – urgent cholecystostomy followed by delayed elective cholecystectomy

Back

Plus –

urgent cholecystostomy followed by delayed elective cholecystectomy

Treatment recommended for ALL patients in selected patient group

Requires urgent management of severe local inflammation by percutaneous gallbladder drainage (i.e., percutaneous cholecystostomy) followed where indicated by delayed elective cholecystectomy 2-3 months later, when the patient's general condition has improved.[34][89]

Patients with Child-Turcotte-Pugh grade A or B liver cirrhosis who undergo elective laparoscopic cholecystectomy have fewer overall postoperative complications, a shorter hospital stay, and quicker resumption of a normal diet than those who undergo the open procedure.[68]

Patients treated with cholecystostomy tube can be discharged with their tube in place after the inflammatory process has resolved clinically. These patients should subsequently undergo a cholangiogram through the cholecystostomy tube (6-8 weeks) to see whether the cystic duct is open. If the duct is open and the patient is a good surgical candidate, they should be referred for cholecystectomy.

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Acute cholecystitis

Treatment algorithm

mild (grade I): stable without signs of perforation/gangrene

supportive care

empiric intravenous antibiotic

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

anaerobic antibiotic cover

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

early laparoscopic cholecystectomy

percutaneous cholecystostomy

endoscopic transpapillary gallbladder drainage or endoscopic ultrasound-guided gallbladder drainage

moderate (grade II): stable with signs of perforation/gangrene

supportive care

empiric intravenous antibiotic

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

anaerobic antibiotic cover

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

early cholecystectomy or cholecystostomy with delayed cholecystectomy

severe (grade III): suspected gangrene/perforation or evidence of organ dysfunction

intensive care admission and supportive care

empiric intravenous antibiotic

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Enterococcus antibiotic cover

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

anaerobic antibiotic cover

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

urgent cholecystostomy followed by delayed elective cholecystectomy