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Treatment of acute calculous cholecystitis

Charles M Vollmer, Jr, MD
Salam F Zakko, MD, FACP, AGAF
Nezam H Afdhal, MD, FRCPI
Section Editor
Stanley W Ashley, MD
Deputy Editor
Wenliang Chen, MD, PhD


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: Clinical manifestations, diagnosis, and management" and "Xanthogranulomatous cholecystitis".)


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 [1].

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 [2]. 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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Literature review current through: Nov 2017. | This topic last updated: Mar 15, 2017.
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  1. Thistle JL, Cleary PA, Lachin JM, et al. The natural history of cholelithiasis: the National Cooperative Gallstone Study. Ann Intern Med 1984; 101:171.
  2. de Mestral C, Rotstein OD, Laupacis A, et al. A population-based analysis of the clinical course of 10,304 patients with acute cholecystitis, discharged without cholecystectomy. J Trauma Acute Care Surg 2013; 74:26.
  3. Riall TS, Zhang D, Townsend CM Jr, et al. Failure to perform cholecystectomy for acute cholecystitis in elderly patients is associated with increased morbidity, mortality, and cost. J Am Coll Surg 2010; 210:668.
  4. Elta GH, Barnett JL. Meperidine need not be proscribed during sphincter of Oddi manometry. Gastrointest Endosc 1994; 40:7.
  5. Thompson DR. Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. Am J Gastroenterol 2001; 96:1266.
  6. Thune A, Baker RA, Saccone GT, et al. Differing effects of pethidine and morphine on human sphincter of Oddi motility. Br J Surg 1990; 77:992.
  7. Fuks D, Cossé C, Régimbeau JM. Antibiotic therapy in acute calculous cholecystitis. J Visc Surg 2013; 150:3.
  8. Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med 2008; 358:2804.
  9. Järvinen H, Renkonen OV, Palmu A. Antibiotics in acute cholecystitis. Ann Clin Res 1978; 10:247.
  10. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010; 50:133.
  11. Kanafani ZA, Khalifé N, Kanj SS, et al. Antibiotic use in acute cholecystitis: practice patterns in the absence of evidence-based guidelines. J Infect 2005; 51:128.
  12. Mazeh H, Mizrahi I, Dior U, et al. Role of antibiotic therapy in mild acute calculus cholecystitis: a prospective randomized controlled trial. World J Surg 2012; 36:1750.
  13. Kune GA, Burdon JG. Are antibiotics necessary in acute cholecystitis? Med J Aust 1975; 2:627.
  14. Landau O, Kott I, Deutsch AA, et al. Multifactorial analysis of septic bile and septic complications in biliary surgery. World J Surg 1992; 16:962.
  15. 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.
  16. Regimbeau JM, Fuks D, Pautrat K, et al. Effect of postoperative antibiotic administration on postoperative infection following cholecystectomy for acute calculous cholecystitis: a randomized clinical trial. JAMA 2014; 312:145.
  17. Feigal DW, Blaisdell FW. The estimation of surgical risk. Med Clin North Am 1979; 63:1131.
  18. Gurusamy KS, Samraj K. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Cochrane Database Syst Rev 2006; :CD005440.
  19. Norrby S, Herlin P, Holmin T, et al. Early or delayed cholecystectomy in acute cholecystitis? A clinical trial. Br J Surg 1983; 70:163.
  20. Lahtinen J, Alhava EM, Aukee S. Acute cholecystitis treated by early and delayed surgery. A controlled clinical trial. Scand J Gastroenterol 1978; 13:673.
  21. McArthur P, Cuschieri A, Sells RA, Shields R. Controlled clinical trial comparing early with interval cholecystectomy for acute cholecystitis. Br J Surg 1975; 62:850.
  22. Brooks KR, Scarborough JE, Vaslef SN, Shapiro ML. No need to wait: an analysis of the timing of cholecystectomy during admission for acute cholecystitis using the American College of Surgeons National Surgical Quality Improvement Program database. J Trauma Acute Care Surg 2013; 74:167.
  23. Gutt CN, Encke J, Köninger J, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg 2013; 258:385.
  24. Banz V, Gsponer T, Candinas D, Güller U. Population-based analysis of 4113 patients with acute cholecystitis: defining the optimal time-point for laparoscopic cholecystectomy. Ann Surg 2011; 254:964.
  25. de Mestral C, Rotstein OD, Laupacis A, et al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis. Ann Surg 2014; 259:10.
  26. Papi C, Catarci M, D'Ambrosio L, et al. Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis. Am J Gastroenterol 2004; 99:147.
  27. Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst Rev 2013; :CD005440.
  28. Macafee DA, Humes DJ, Bouliotis G, et al. Prospective randomized trial using cost-utility analysis of early versus delayed laparoscopic cholecystectomy for acute gallbladder disease. Br J Surg 2009; 96:1031.
  29. Dua A, Dua A, Desai SS, et al. Gender based differences in management and outcomes of cholecystitis. Am J Surg 2013; 206:641.
  30. Yadav RP, Adhikary S, Agrawal CS, et al. A comparative study of early vs. delayed laparoscopic cholecystectomy in acute cholecystitis. Kathmandu Univ Med J (KUMJ) 2009; 7:16.
  31. Wu XD, Tian X, Liu MM, et al. Meta-analysis comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 2015; 102:1302.
  32. Blohm M, Österberg J, Sandblom G, et al. The Sooner, the Better? The Importance of Optimal Timing of Cholecystectomy in Acute Cholecystitis: Data from the National Swedish Registry for Gallstone Surgery, GallRiks. J Gastrointest Surg 2017; 21:33.
  33. Farooq T, Buchanan G, Manda V, et al. Is early laparoscopic cholecystectomy safe after the "safe period"? J Laparoendosc Adv Surg Tech A 2009; 19:471.
  34. Litwin DE, Cahan MA. Laparoscopic cholecystectomy. Surg Clin North Am 2008; 88:1295.
  35. Pessaux P, Tuech JJ, Regenet N, et al. [Laparoscopic cholecystectomy in the treatment of acute cholecystitis. Prospective non-randomized study]. Gastroenterol Clin Biol 2000; 24:400.
  36. Roulin D, Saadi A, Di Mare L, et al. Early Versus Delayed Cholecystectomy for Acute Cholecystitis, Are the 72 hours Still the Rule?: A Randomized Trial. Ann Surg 2016; 264:717.
  37. Gomes RM, Mehta NT, Varik V, Doctor NH. No 72-hour pathological boundary for safe early laparoscopic cholecystectomy in acute cholecystitis: a clinicopathological study. Ann Gastroenterol 2013; 26:340.
  38. Soper NJ, Stockmann PT, Dunnegan DL, Ashley SW. Laparoscopic cholecystectomy. The new 'gold standard'? Arch Surg 1992; 127:917.
  39. Wiesen SM, Unger SW, Barkin JS, et al. Laparoscopic cholecystectomy: the procedure of choice for acute cholecystitis. Am J Gastroenterol 1993; 88:334.
  40. Wilson RG, Macintyre IM, Nixon SJ, et al. Laparoscopic cholecystectomy as a safe and effective treatment for severe acute cholecystitis. BMJ 1992; 305:394.
  41. Johansson M, Thune A, Nelvin L, et al. Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis. Br J Surg 2005; 92:44.
  42. Yamashita Y, Takada T, Kawarada Y, et al. Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007; 14:91.
  43. Overby DW, Apelgren KN, Richardson W, et al. SAGES guidelines for the clinical application of laparoscopic biliary tract surgery. Surg Endosc 2010; 24:2368.
  44. NIH releases consensus statement on gallstones, bile duct stones and laparoscopic cholecystectomy. Am Fam Physician 1992; 46:1571.
  45. Vollmer CM Jr, Callery MP. Biliary injury following laparoscopic cholecystectomy: why still a problem? Gastroenterology 2007; 133:1039.
  46. Khan MH, Howard TJ, Fogel EL, et al. Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: experience at a large tertiary referral center. Gastrointest Endosc 2007; 65:247.
  47. Baron TH, Grimm IS, Swanstrom LL. Interventional Approaches to Gallbladder Disease. N Engl J Med 2015; 373:357.
  48. Bernard HR, Hartman TW. Complications after laparoscopic cholecystectomy. Am J Surg 1993; 165:533.
  49. National Institutes of Health Consensus Development Conference Statement on Gallstones and Laparoscopic Cholecystectomy. Am J Surg 1993; 165:390.
  50. Morse BC, Smith JB, Lawdahl RB, Roettger RH. Management of acute cholecystitis in critically ill patients: contemporary role for cholecystostomy and subsequent cholecystectomy. Am Surg 2010; 76:708.
  51. McGillicuddy EA, Schuster KM, Barre K, et al. Non-operative management of acute cholecystitis in the elderly. Br J Surg 2012; 99:1254.
  52. Bourikian S, Anand RJ, Aboutanos M, et al. Risk factors for acute gangrenous cholecystitis in emergency general surgery patients. Am J Surg 2015; 210:730.
  53. Hatzidakis AA, Prassopoulos P, Petinarakis I, et al. Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment. Eur Radiol 2002; 12:1778.
  54. Melin MM, Sarr MG, Bender CE, van Heerden JA. Percutaneous cholecystostomy: a valuable technique in high-risk patients with presumed acute cholecystitis. Br J Surg 1995; 82:1274.
  55. Ito K, Fujita N, Noda Y, et al. Percutaneous cholecystostomy versus gallbladder aspiration for acute cholecystitis: a prospective randomized controlled trial. AJR Am J Roentgenol 2004; 183:193.
  56. Davis CA, Landercasper J, Gundersen LH, Lambert PJ. Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results. Arch Surg 1999; 134:727.
  57. Byrne MF, Suhocki P, Mitchell RM, et al. Percutaneous cholecystostomy in patients with acute cholecystitis: experience of 45 patients at a US referral center. J Am Coll Surg 2003; 197:206.
  58. Cherng N, Witkowski ET, Sneider EB, et al. Use of cholecystostomy tubes in the management of patients with primary diagnosis of acute cholecystitis. J Am Coll Surg 2012; 214:196.
  59. Akyürek N, Salman B, Yüksel O, et al. Management of acute calculous cholecystitis in high-risk patients: percutaneous cholecystotomy followed by early laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2005; 15:315.
  60. Karakayali FY, Akdur A, Kirnap M, et al. Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis. Hepatobiliary Pancreat Dis Int 2014; 13:316.
  61. Simorov A, Ranade A, Parcells J, et al. Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study. Am J Surg 2013; 206:935.
  62. Atar E, Bachar GN, Berlin S, et al. Percutaneous cholecystostomy in critically ill patients with acute cholecystitis: complications and late outcome. Clin Radiol 2014; 69:e247.
  63. Horn T, Christensen SD, Kirkegård J, et al. Percutaneous cholecystostomy is an effective treatment option for acute calculous cholecystitis: a 10-year experience. HPB (Oxford) 2015; 17:326.
  64. Abi-Haidar Y, Sanchez V, Williams SA, Itani KM. Revisiting percutaneous cholecystostomy for acute cholecystitis based on a 10-year experience. Arch Surg 2012; 147:416.
  65. Smith TJ, Manske JG, Mathiason MA, et al. Changing trends and outcomes in the use of percutaneous cholecystostomy tubes for acute cholecystitis. Ann Surg 2013; 257:1112.
  66. Kortram K, van Ramshorst B, Bollen TL, et al. Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): study protocol for a randomized controlled trial. Trials 2012; 13:7.
  67. Joseph T, Unver K, Hwang GL, et al. Percutaneous cholecystostomy for acute cholecystitis: ten-year experience. J Vasc Interv Radiol 2012; 23:83.
  68. Dewhurst C, Kane RA, Mhuircheartaigh JN, et al. Complication rate of ultrasound-guided percutaneous cholecystostomy in patients with coagulopathy. AJR Am J Roentgenol 2012; 199:W753.
  69. de Mestral C, Gomez D, Haas B, et al. Cholecystostomy: a bridge to hospital discharge but not delayed cholecystectomy. J Trauma Acute Care Surg 2013; 74:175.
  70. Burhenne HJ, Stoller JL. Minicholecystostomy and radiologic stone extraction in high-risk cholelithiasis patients. Preliminary experience. Am J Surg 1985; 149:632.
  71. Itoi T, Sofuni A, Itokawa F, et al. Endoscopic transpapillary gallbladder drainage in patients with acute cholecystitis in whom percutaneous transhepatic approach is contraindicated or anatomically impossible (with video). Gastrointest Endosc 2008; 68:455.
  72. Kjaer DW, Kruse A, Funch-Jensen P. Endoscopic gallbladder drainage of patients with acute cholecystitis. Endoscopy 2007; 39:304.
  73. Lee TH, Park DH, Lee SS, et al. Outcomes of endoscopic transpapillary gallbladder stenting for symptomatic gallbladder diseases: a multicenter prospective follow-up study. Endoscopy 2011; 43:702.
  74. McCarthy ST, Tujios S, Fontana RJ, et al. Endoscopic Transpapillary Gallbladder Stent Placement Is Safe and Effective in High-Risk Patients Without Cirrhosis. Dig Dis Sci 2015; 60:2516.
  75. Tujios SR, Rahnama-Moghadam S, Elmunzer JB, et al. Transpapillary Gallbladder Stents Can Stabilize or Improve Decompensated Cirrhosis in Patients Awaiting Liver Transplantation. J Clin Gastroenterol 2015; 49:771.
  76. Peñas-Herrero I, de la Serna-Higuera C, Perez-Miranda M. Endoscopic ultrasound-guided gallbladder drainage for the management of acute cholecystitis (with video). J Hepatobiliary Pancreat Sci 2015; 22:35.
  77. Jang JW, Lee SS, Song TJ, et al. Endoscopic ultrasound-guided transmural and percutaneous transhepatic gallbladder drainage are comparable for acute cholecystitis. Gastroenterology 2012; 142:805.
  78. Karamanos E, Sivrikoz E, Beale E, et al. Effect of diabetes on outcomes in patients undergoing emergent cholecystectomy for acute cholecystitis. World J Surg 2013; 37:2257.