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 in adults" and "Approach to the patient with incidental gallstones" and "Choledocholithiasis: Clinical manifestations, diagnosis, and management" and "Acute cholecystitis: Pathogenesis, clinical features, and diagnosis" and "Acalculous cholecystitis" and "Xanthogranulomatous cholecystitis".)
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 . 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. However, it is not clear that antibiotics are required for the treatment of uncomplicated acute 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 . 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 .
The guidelines of the Infectious Diseases Society of America (IDSA) recommend that antimicrobial therapy be instituted if infection is suspected on the basis of laboratory (more than 12,500 white cells per cubic millimeter) or clinical findings (temperature of more than 38.5°C), and radiographic findings (eg, air in the gallbladder or gallbladder wall) . Routine antibiotics are also recommended in older patients or those with diabetes or immunodeficiency [2,5]. When antibiotic therapy is initiated, the duration is tailored to clinical improvement. The need for prophylactic antibiotics at the time of surgery in the absence of clinical symptoms/signs of biliary infection is discussed elsewhere. (See "Open cholecystectomy", section on 'Prophylactic antibiotics' and "Laparoscopic cholecystectomy", section on 'Antibiotics'.)