Management

The patient with acute cholecystitis is initially managed with intravenous fluid rehydration and nasogastric tube decompression if vomiting is present. Antibiotics directed against gram-negative organisms are recommended to be initiated preop-eratively.

After resuscitation has been optimized, cholecystectomy is indicated with the laparoscopic approach being the most favored. The timing of operation has been well-studied with trials showing that early cholecystectomy is preferable over a delayed approach. If symptoms began within 72 hours of presentation, a laparoscopic cholecystectomy should be performed at the first available elective OR time. If presentation is >72 hrs after symptom onset and the patient is responding to medical management (nasogastric suction, fluid resuscitation, antibiotics), then cholecystec-tomy can be delayed 4-6 weeks to allow for recovery from the acute attack. This does carry an approximately 20-50% risk of recurrence, and the patient may default after discharge. For these reasons most advocate early cholecystectomy anyway. If the patient deteriorates or does not improve, this is an indication for surgery. Also, the presence of an inflammatory right upper quadrant mass, gas in gallbladder or biliary tract, and peritonitis each call for emergency operation.

If the patient's comorbid condition deems them to be high-risk and precludes surgical intervention, a cholecystotomy tube can be placed to drain the gallbladder until the patient has recovered enough to tolerate cholecystectomy. Following resolution of the acute process, cholangiography is performed and residual stones are evacuated prior to removal of the tube.

Gallstones discovered incidentally do not require treatment, and therapy should only begin if the patient becomes symptomatic. Exceptions are all children and those patients with sickle cell disease, a nonfunctioning gallbladder, and calcified gallbladder (up to 50% associated with cancer of the gallbladder.)

Prophylactic cholecystectomy is not recommended in diabetic patients because the operative risk outweighs the benefit of cholecystectomy. In patients undergoing laparotomy for other reasons, if calculi are noted, cholecystectomy is appropriate if the primary operation is without apparent complication and exposure is adequate.

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