Treatment of acute calculous cholecystitis
- Charles M Vollmer, Jr, MD
Charles M Vollmer, Jr, MD
- Professor of Surgery
- University of Pennsylvania School of Medicine
- Salam F Zakko, MD, FACP
Salam F Zakko, MD, FACP
- Executive Director, Connecticut Gastroenterology Institute
- Clinical Professor of Medicine, University of Connecticut School of Medicine
- Nezam H Afdhal, MD, FRCPI
Nezam H Afdhal, MD, FRCPI
- Senior Physician in Hepatology
- Beth Israel Deaconess Medical Center
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 (ie, acute calculous cholecystitis). Complications include the development of gangrene and gallbladder perforation, which can be life-threatening.
The treatment of acute calculous cholecystitis will be reviewed here. The approach to patients with asymptomatic gallstones, the approach to the pregnant patient with gallstones, and the clinical manifestations and diagnosis of biliary colic, acute cholecystitis and related conditions, such as acalculous and xanthogranulomatous cholecystitis, are discussed separately. (See "Uncomplicated gallstone disease in adults" and "Approach to the patient with incidental gallstones" and "Choledocholithiasis: Clinical manifestations, diagnosis, and management" and "Gallstones in pregnancy" and "Acute cholecystitis: Pathogenesis, clinical features, and diagnosis" and "Acalculous cholecystitis" and "Xanthogranulomatous cholecystitis".)
OVERVIEW OF TREATMENT
Once a patient develops symptoms or complications related to gallstones (biliary colic, acute cholecystitis, cholangitis, and/or pancreatitis), definitive therapy (cholecystectomy, cholecystostomy, endoscopic sphincterotomy, medical gallstone dissolution) is recommended. Without treatment to eliminate the gallstones, the likelihood of subsequent symptoms or complications is high. Complications include the development of gangrene and gallbladder perforation, which can be life-threatening. (See 'Morbidity and mortality' below.)
●In the National Cooperative Gallstone Study, a trial of nonsurgical treatment with chenodiol for biliary tract pain, demonstrated that the risk of recurrent symptoms for untreated patients was approximately 70 percent during the two years following initial presentation .
●In a cohort study of 25,397 patients from Ontario, Canada with a first episode of uncomplicated acute cholecystitis, 10,304 did not undergo cholecystectomy on their first admission . During a median 3.4 years of follow-up, 24 percent of patients had a gallstone-related event with the majority of events occurring within the first year (88 percent). The risk was highest among 18 to 34-year-old patients. Among the events, 30 percent were for biliary obstruction or pancreatitis.
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- OVERVIEW OF TREATMENT
- SUPPORTIVE CARE
- Pain control
- MEDICAL RISK ASSESSMENT
- LOW-RISK PATIENTS
- Timing of cholecystectomy
- Surgical approach
- HIGH-RISK PATIENTS
- Antibiotic therapy
- Gallbladder drainage
- - Percutaneous
- - Endoscopic
- Transpapillary drainage
- Transmural drainage
- - Surgical
- Subsequent care following drainage
- - Effective drainage
- - Ineffective drainage
- MORBIDITY AND MORTALITY
- Prevention of recurrent gallstones
- SUMMARY AND RECOMMENDATIONS