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Acute cholecystitis — Clinical Guidelines

Overview

Acute cholecystitis is an inflammatory condition of the gallbladder, often requiring surgical intervention, typically laparoscopic cholecystectomy, to manage symptoms and prevent complications. 1 4

Diagnosis

Clinical presentation includes right upper quadrant pain, fever, and leukocytosis.

Imaging studies such as abdominal ultrasound and CT are essential for diagnosis.

Grading systems like the Tokyo Guidelines help stratify severity (Grade I/II/III). 3 4

Management

First-line treatment: Emergency laparoscopic cholecystectomy is the gold standard for most patients. 1 4

Adjunctive treatments:

- Antibiotics: Broad-spectrum antibiotics are often initiated preoperatively. 9 22 - Fluorescent cholangiography: Utilized to enhance anatomical identification and reduce complications. 6 - Percutaneous cholecystostomy: Recommended for high-risk patients unsuitable for immediate surgery. 11 22

Antithrombotic therapy management: Careful consideration required; outcomes vary with perioperative management. 2 15

Special Populations

Elderly patients: May benefit from delayed cholecystectomy after initial management with antibiotics or percutaneous drainage. 17 22

High-risk surgical patients: Consider percutaneous transhepatic gallbladder drainage (PTGBD) combined with delayed LC. 14

Comorbidities: Patients on antithrombotic therapy require tailored perioperative management to mitigate bleeding risks. 2 15

Key Recommendations

Perform emergency laparoscopic cholecystectomy as the primary treatment for acute cholecystitis in suitable patients. (Evidence: Strong 1 4)

Use percutaneous cholecystostomy for high-risk patients who are not immediate surgical candidates. (Evidence: Moderate 11 22)

Implement careful management of antithrombotic therapy perioperatively to balance thromboembolic and bleeding risks. (Evidence: Moderate 2 15)

Consider delayed cholecystectomy in elderly or critically ill patients managed initially with antibiotics or percutaneous drainage. (Evidence: Moderate 17)

Utilize advanced imaging techniques such as fluorescent cholangiography to enhance surgical safety during laparoscopic procedures. (Evidence: Weak 6)

References

1 Carramiñana-Nuño R, Borrego-Estella V, Millán-Mateos A, Medina-Mora L, Gasós-García M, Otero-Romero D et al.. Role of intraoperative indocyanine green roadmap as a safety measure in emergent laparoscopic cholecystectomy. Updates in surgery 2025. link 2 Harada K, Uemoto Y, Fujikawa T. How antithrombotic therapy influences the clinical outcomes of emergency laparoscopic cholecystectomy for acute cholecystitis. Surgery today 2025. link 3 Groszman L, Hopkins B, AlShahwan N, Fraser S, Bergman S, Pelletier JS et al.. Predicting Acute Cholecystitis on Final Pathology to Prioritize Surgical Urgency: An Evaluation of the Tokyo Criteria and Development of a Novel Predictive Score. The Journal of surgical research 2025. link 4 Liu Q, Han X, Zhang G, Huang H, Chen S, Wang H et al.. Proactive emergency laparoscopic cholecystectomy for complex acute cholecystitis: a prospective cohort at a national emergency center in China. International journal of surgery (London, England) 2025. link 5 Chan KS, Baey S, Shelat VG, Junnarkar SP. Are outcomes for emergency index-admission laparoscopic cholecystectomy performed by hepatopancreatobiliary surgeons better compared to non-hepatopancreatobiliary surgeons? A 10-year audit using 1:1 propensity score matching. Hepatobiliary & pancreatic diseases international : HBPD INT 2024. link 6 Pesce A, Fabbri N, Bonazza L, Feo C. The role of fluorescent cholangiography to improve operative safety in different severity degrees of acute cholecystitis during emergency laparoscopic cholecystectomy: a prospective cohort study. International journal of surgery (London, England) 2024. link 7 Mutlu IN, Guzelbey T, Erdim C, Dablan A, Kılıckesmez O. A Comparative Analysis of Erector Spinae Plane Block Versus Conscious Sedation in Managing Percutaneous Cholecystostomy Pain. Cardiovascular and interventional radiology 2024. link 8 Slama EM, Hosseini M, Staszak RM, Setya VR. Open Cholecystostomy Under Local Anesthesia for Acute Cholecystitis in the Elderly and High-Risk Surgical Patients. The American surgeon 2022. link 9 Yoon JH, Paik KY, Chung HY, Oh JS. Clinical implication of bactibilia in moderate to severe acute cholecystitis undergone cholecystostomy following cholecystectomy. Scientific reports 2021. link 10 Romano L, Giuliani A, Pessia B, Mattei A, Fiasca F, Tonelli E et al.. The early prediction of mortality in acute cholecystitis: Temperature, Neutrophils and Multiple organ failure (TNM) score. European review for medical and pharmacological sciences 2021. link 11 De Geus T, Moriarty HK, Waters PS, O'Reilly MK, Lawler L, Geoghegan T et al.. Outcomes of Patients Treated With Upfront Cholecystostomy for Severe Acute Cholecystitis. Surgical laparoscopy, endoscopy & percutaneous techniques 2020. link 12 Wiggins T, Markar SR, MacKenzie H, Faiz O, Mukherjee D, Khoo DE et al.. Optimum timing of emergency cholecystectomy for acute cholecystitis in England: population-based cohort study. Surgical endoscopy 2019. link 13 Yoshioka R, Tomimaru Y, Noguchi K, Noura S, Imamura H, Dono K. The "Off-Hour Effect" in Urgent Laparoscopic Cholecystectomy for Acute Cholecystitis. Surgical laparoscopy, endoscopy & percutaneous techniques 2019. link 14 Jia B, Liu K, Tan L, Jin Z, Liu Y. Percutaneous Transhepatic Gallbladder Drainage Combined with Laparoscopic Cholecystectomy . The American surgeon 2018. link 15 Kawamoto Y, Fujikawa T, Sakamoto Y, Emoto N, Takahashi R, Kawamura Y et al.. Effect of antithrombic therapy on bleeding complications in patients receiving emergency cholecystectomy for acute cholecystitis. Journal of hepato-biliary-pancreatic sciences 2018. link 16 Vaccari S, Lauro A, Cervellera M, Casella G, D'Andrea V, Di Matteo FM et al.. Early versus delayed approach in cholecystectomy after admission to an emergency department. A multicenter retrospective study. Il Giornale di chirurgia 2018. link 17 Joliat GR, Longchamp G, Du Pasquier C, Denys A, Demartines N, Melloul E. Delayed Cholecystectomy for Acute Cholecystitis in Elderly Patients Treated Primarily with Antibiotics or Percutaneous Drainage of the Gallbladder. Journal of laparoendoscopic & advanced surgical techniques. Part A 2018. link 18 Yun SH, Park MS, Lee JU, Yang MA, Han SH, Lee YJ et al.. Bedside Endoscopic Ultrasound-guided Transgastric Gallbladder Aspiration and Lavage in a High-risk Surgical Case Due to Acute Cholecystitis Accompanied by Multiorgan Failure. The Korean journal of gastroenterology = Taehan Sohwagi Hakhoe chi 2015. link 19 Kim YH, Kim YJ, Shin TB. Fluoroscopy-guided percutaneous gallstone removal using a 12-Fr sheath in high-risk surgical patients with acute cholecystitis. Korean journal of radiology 2011. link 20 Yun SS, Hwang DW, Kim SW, Park SH, Park SJ, Lee DS et al.. Better treatment strategies for patients with acute cholecystitis and American Society of Anesthesiologists classification 3 or greater. Yonsei medical journal 2010. link 21 Laurila J, Laurila PA, Saarnio J, Koivukangas V, Syrjälä H, Ala-Kokko TI. Organ system dysfunction following open cholecystectomy for acute acalculous cholecystitis in critically ill patients. Acta anaesthesiologica Scandinavica 2006. link 22 Patel M, Miedema BW, James MA, Marshall JB. Percutaneous cholecystostomy is an effective treatment for high-risk patients with acute cholecystitis. The American surgeon 2000. link 23 Borly L, Højgaard L, Grønvall S, Stage JG. Human gallbladder pressure and volume: validation of a new direct method for measurements of gallbladder pressure in patients with acute cholecystitis. Clinical physiology (Oxford, England) 1996. link 24 Boland GW, Lee MJ, Leung J, Mueller PR. Percutaneous cholecystostomy in critically ill patients: early response and final outcome in 82 patients. AJR. American journal of roentgenology 1994. link 25 Browning PD, McGahan JP, Gerscovich EO. Percutaneous cholecystostomy for suspected acute cholecystitis in the hospitalized patient. Journal of vascular and interventional radiology : JVIR 1993. link71915-6) 26 Eldar S, Abrahamson J, Issaq E, Kedar SS. Postoperative acute cholecystitis complicating urologic operations. Urology 1984. link90113-4)

Acute cholecystitis