Overview
This interview with Dr. Anthony Charles reviews the epidemiology, risk factors, diagnosis, and management of acute cholecystitis, with emphasis on current treatment standards and special populations.
Epidemiology and Risk Factors
- Approximately 200,000 people in the U.S. are diagnosed with acute cholecystitis annually.
- Around 25 million people in the U.S. have gallstones; 20% become symptomatic, 5% develop acute cholecystitis.
- Risk factors for gallstones include hemolytic anemias, obesity, rapid weight loss, certain medications, female sex, age, and pregnancy.
- Pregnancy increases risk, particularly in the prenatal and postpartum periods.
Pathophysiology and Classification
- Acute cholecystitis progresses through acute (congestion/edema), hemorrhagic (possible necrosis), and purulent (infection) phases.
- Complicated acute cholecystitis involves gangrene, perforation, bilioenteric fistula, or gallstone ileus.
- Acalculous cholecystitis occurs in 5-10% of cases, mainly in critically ill patients, due to bile stasis and hypoperfusion.
Diagnosis
- Ultrasonography is the initial imaging choice; sensitivity ~81%, specificity ~80%.
- Typical ultrasound findings: gallbladder distention, wall edema, pericholecystic fluid, gallstones or sludge.
- If ultrasound is inconclusive, CT or MRI (MRCP) can be used; hepatobiliary scintigraphy (HIDA scan) is the gold standard.
- HIDA scan: sensitivity 96%, specificity 90%.
Treatment Approaches
- Early laparoscopic cholecystectomy (within 1–3 days of symptom onset) reduces hospital stay, complications, and recovery time.
- Conversion to open cholecystectomy occurs in 2–15% of laparoscopic cases; risk factors include delayed surgery, male sex, older age, high BMI, prior abdominal surgery, and complicated cholecystitis.
- Pregnant and elderly patients should receive standard treatment, with surgery recommended in any trimester if indicated.
Perioperative Management
- Preoperative IV antibiotics are recommended, targeting gram-negative bacteria.
- No benefit found in extended postoperative antibiotics after gallbladder removal.
Alternative Interventions
- Percutaneous cholecystostomy tube may be considered for critically ill or high-risk patients, but generally results in worse outcomes compared to surgery and should be reserved for exceptional cases.
Health Disparities
- Underrepresented minorities in the U.S. are more likely to present later with complicated cholecystitis, possibly due to healthcare access disparities.
Recommendations / Advice
- Early laparoscopic cholecystectomy should be the standard of care for acute cholecystitis.
- Reserve percutaneous cholecystostomy for patients with prohibitive surgical risk.