Surgery is the gold standard treatment of acute gall bladder inflammation. (Acute Cholecystitis)

How to treat acute gall bladder infection?

As soon as patient come Initial treatment with antibiotics active against enteric bacteria should begin.

The definitive treatment for acute gall bladder inflammation (acute cholecystitis) is cholecystectomy. From the time this operation was first performed in 1882 by Langenbuch, open cholecystectomy has been the standard of care for patients with acute cholecystitis. With the advent of laparoscopic cholecystectomy in the 1980s, the standard approach has changed such that cholecystectomy is now routinely performed laparoscopically.

Only issue is timing of surgery.

The conversion rate to an open procedure is higher for patients with acute cholecystitis compared with patients undergoing elective operations but most patients with acute cholecystitis (>80%) can undergo laparoscopic cholecystectomy successfully.

Laparoscopic subtotal cholecystectomy (LSC) has also been evaluated as a means of decreasing the conversion rate to open procedure in patients with acute cholecystitis  This procedure involves leaving the wall of the gallbladder when it is significantly difficult to dissect from the liver bed, Indeed, in the face of severe inflammatory change, such an approach is safter than risking injury .Horiuchi and colleagues (2008) demonstrated a significant decrease in conversion rate to open procedure with the use of these techniques with no increase in postoperative complications. Laparoscopic cholecystectomy remains the standard therapy for definitive treatment of patients with acute cholecystitis, with conversion to an open procedure if necessary.

In patients with a high perioperative risk from sepsis or other underlying medical comorbidities, initial treatment of acute cholecystitis with percutaneous tube placement is preferred, These tubes can be placed using either sonographic or CT guidance. This procedure effectively decompresses the gallbladder, evacuating the infected bile and relieving the pain associated with gallbladder distension, and it is associated with a low complication rate After stabilization of the patient, and if the clinical situation otherwise warrants, delayed cholecystectomy should be performed, which often can be done laparoscopically. Akyürek and colleagues (2005) demonstrated decreased hospital stay and cost in high-risk patients undergoing percutaneous cholecystostomy followed by early laparoscopic cholecystectomy compared with those treated conservatively with intravenous (IV) antibiotics and bowel rest followed by delayed cholecystectomy.

Timing of Surgery

The optimal interval of time between the diagnosis of acute cholecystitis and definitive treatment with cholecystectomy has been the subject of many prospective randomized trials, nine evaluating open cholecystectomy and five evaluating laparoscopic cholecystectomy. The concern in operating on patients with early cholecystitis (typically defined as <3 days) is the potential for increased postoperative complications, including common bile duct injury. The risk of performing cholecystectomy late (weeks after the diagnosis of cholecystitis) is that a subset of patients have recurrent symptoms during the period between diagnosis and surgical treatment, which leads to recurrent hospital admissions and urgent surgery .In multiple randomized prospective trials evaluating the timing of open cholecystectomy, patients undergoing early operation experienced no increased perioperative complications and had a shorter length of hospital stay compared with patients undergoing delayed operation.

The majority of trials of early versus delayed laparoscopic cholecystectomy define “early” as within 72 hours of symptom onset. A recent nonrandomized, prospective study by Tzovaras and colleagues (2006) assessed 129 patients undergoing laparoscopic cholecystectomy for acute cholecystitis during the index admission. The patients were divided into three groups regarding the timing of their surgery from symptom onset: within 3 days, between 4 and 7 days, and after 7 days. They found no significant difference in conversion rate, or postoperative hospital stay among these groups and thus suggest that the benefits of early cholecystectomy are not limited to patients who present within 72 hours of symptom onset.

Take home points:

·      Cholecystectomy preferably laproscopic is gold standard treatment.

·      If expertise available early cholecystectomy should be done.

·      There is no hard and fast timing for cholecystectomy should be decided upon patient condition and expertise available.

·      Percutaneous cholecystectomy should be done in septic/sick patients not suitable for surgery.

·      Subtotal or partial cholecystectomy should be considered as a option before converting to open

·      End of the day goal should be to treat the patient and not the way or approach.