Management of Acute Calculous Cholecystitis

1. Diagnosis

Clinical Features

• RUQ or epigastric pain (constant, >6 hours), fever, nausea/vomiting
• Murphy's sign: inspiratory arrest on deep palpation of the RUQ (sonographic Murphy's sign is operator-dependent)
• Leukocytosis; mild elevations of ALP, bilirubin, and transaminases
• Profound jaundice is rare — if present, suspect cholangitis or Mirizzi syndrome

Imaging

RUQ ultrasound is the diagnostic test of choice. CT is recommended when emphysematous cholecystitis or complications are suspected. — Sabiston Textbook of Surgery

2. Tokyo Guidelines 2018 (TG18) — Severity Grading

3. Initial Resuscitation and Supportive Care

• IV fluid resuscitation — restore perfusion and electrolyte balance
• NPO (nothing by mouth)
• Parenteral analgesia (narcotics for pain control)
• IV antibiotics — bile cultures positive in >40% of patients

Antibiotic Selection

• Mild–moderate (Grade I–II): Cefoxitin (2nd-gen cephalosporin) or ampicillin-sulbactam
• Severe (Grade III) or broad-spectrum needed: Piperacillin-tazobactam or 3rd-generation cephalosporin + metronidazole
• Emphysematous/gangrenous cholecystitis: Must cover anaerobes (metronidazole or piperacillin-tazobactam)
• Organisms targeted: E. coli, Klebsiella, Enterobacter, Proteus (gram-negative enteric bacilli); Enterococcus, Streptococcus (gram-positive); anaerobes (~15% of isolates); Clostridium in emphysematous disease

If source control is achieved with surgery, postoperative antibiotics are NOT indicated for mild-to-moderate cholecystitis. Continue antibiotics postoperatively for severe infection, intraoperative gallbladder perforation, or gangrenous cholecystitis. — Sleisenger & Fordtran's GI and Liver Disease

4. Definitive Treatment: Cholecystectomy

Timing: Early vs. Delayed

Surgical Approach

• Laparoscopic cholecystectomy is feasible in most cases and is the procedure of choice
• If severe inflammation obscures the hepatocystic triangle: laparoscopic subtotal fenestrating cholecystectomy or conversion to open
• Intraoperative cholangiography is especially valuable in acute cholecystitis to confirm ductal anatomy and detect CBD stones
• Routine placement of surgical drainage catheters after laparoscopic cholecystectomy is not warranted and may be harmful

Management Algorithm (Mulholland & Greenfield's Surgery, Algorithm 8.2)

5. Non-Surgical Options for High-Risk Patients

Percutaneous Cholecystostomy (PC)

• Gallbladder drainage performed under ultrasound or fluoroscopic guidance
• TG18 recommends PC for Grade II–III cholecystitis in high-surgical-risk patients failing antibiotics and supportive care
• Earlier TG versions specified: Grade II with symptoms >72 h failing antibiotics, OR any Grade III
• 30-day mortality after PC: 9–21% (reflecting the severity of underlying illness)
• Residual stones can be removed via the tube; however, ~50% of patients develop recurrent biliary symptoms
• After recovery, interval laparoscopic cholecystectomy should be performed if the patient's condition permits

Endoscopic Transmural Gallbladder Drainage

• EUS-guided endoluminal stent from gallbladder to duodenum (EUS-GBD)
• As effective as percutaneous drainage for decompression in non-surgical patients
• Caveat: If future surgery becomes possible, it requires additional repair of the duodenotomy site — so it is reserved for patients who will definitively remain non-surgical candidates

6. Special Populations

7. Complications to Recognize and Manage

8. Summary Algorithm

Acute Calculous Cholecystitis Confirmed
         ↓
    IV fluids + NPO + Analgesia + IV Antibiotics
         ↓
    Assess Severity (TG18 Grade I / II / III)
    + Surgical Risk (ASA / comorbidities)
         ↓
   ┌─────────────────────────────────┐
   │ Grade I–II, Low surgical risk  │ → Early Laparoscopic Cholecystectomy
   │                                │   (within 72 hours, ideally 24–48 h)
   └─────────────────────────────────┘
         ↓
   ┌─────────────────────────────────────────┐
   │ Grade II–III, High surgical risk       │ → Percutaneous Cholecystostomy
   │ (organ failure, severe comorbidities)  │   + Antibiotics
   └─────────────────────────────────────────┘
              ↓ (after recovery)
         Interval Laparoscopic Cholecystectomy
              (if patient becomes operative candidate)

• Sleisenger & Fordtran's GI and Liver Disease, Ch. 90, p. 1263
• Sabiston Textbook of Surgery, Ch. Biliary, pp. 1824–1831
• Mulholland & Greenfield's Surgery, 7e, pp. 461–462
• Current Surgical Therapy, 14e, pp. 510–511
• Tokyo Guidelines 2018 (TG18)