Red Flags
- Cholangitis (Charcot's triad: fever, jaundice, RUQ pain) — emergency ERCP within 24 h; broad-spectrum antibiotic; admit[1]
- Gangrenous or perforated cholecystitis (peritonism, gas in gallbladder wall, sepsis) — emergency cholecystectomy or percutaneous cholecystostomy[1]
- Acute cholecystitis with sepsis or organ dysfunction — sepsis pathway; urgent source control via early cholecystectomy or percutaneous drainage[1]
- Pregnancy with acute cholecystitis — laparoscopic cholecystectomy any trimester preferred over conservative management; multidisciplinary care[1]
First-line treatment
Interventions
- Early laparoscopic cholecystectomyWhen expertise is available, perform early laparoscopic cholecystectomy as soon as possible, within 7 days of hospital admission and 10 days of symptom onset. Consider subtotal cholecystectomy if anatomy is difficult to identify and injury risk is high; convert to open for severe local inflammation, adhesions, bleeding in Calot’s triangle or suspected bile-duct injury. [2]
- Risk stratification (TG18 grades I-III)Assess whether the patient is suitable for surgery, distinguishing high risk from inability to tolerate an operation. WSES 2020 supports laparoscopic cholecystectomy when feasible, including many high-risk patients; nonoperative management or gallbladder drainage is for patients refusing surgery or not suitable for it. [2]
- Percutaneous cholecystostomy (rescue)Gallbladder drainage is an option for acute cholecystitis when the patient is not suitable for surgery. Reassess for delayed cholecystectomy after clinical improvement when feasible; high-risk status alone must not be equated with surgical ineligibility. [2]
- Common bile duct evaluationRisk-stratify for common-bile-duct stones. Common-bile-duct stones visualized on ultrasound support direct ERCP or operative evaluation; bilirubin>4 mg/dL, or an enlarged CBD with bilirubin 1.8–4 mg/dL, warrants second-level assessment with MRCP, EUS, intraoperative cholangiography or laparoscopic ultrasound. Raised liver tests or duct diameter alone do not establish choledocholithiasis. [2]
- Antibiotic durationDo not routinely give postoperative antibiotics for uncomplicated acute calculous cholecystitis after cholecystectomy has controlled the focus. For complicated infection, select treatment by likely pathogens, local resistance and relevant cultures, with reassessment. This 2020 WSES guideline does not establish the stored fixed 4–7 day cholangitis regimen. [2]
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Co-amoxiclav (community-acquired, mild)[1] | Aminopenicillin + beta-lactamase inhibitor | 1.2 g IV every 8 h; switch to oral 625 mg TDS once tolerating diet | Per local protocol | First-line for mild community-acquired cholecystitis without severity features; review at 48 h with cultures |
| Piperacillin-tazobactam[1] | Beta-lactam + beta-lactamase inhibitor | 4.5 g IV every 6–8 h | Per local protocol | Moderate-severe or healthcare-associated cholecystitis; broad gram-positive, gram-negative, anaerobic; renal dose adjustment |
| Ceftriaxone + metronidazole[1] | Third-generation cephalosporin + nitroimidazole | Ceftriaxone 1–2 g IV daily + metronidazole 500 mg IV every 8 h | Ceftriaxone 50–80 mg/kg/day; metronidazole 7.5 mg/kg every 8 h | Alternative for mild-moderate community-acquired; oral switch to cefuroxime + metronidazole when improving |
| Meropenem (severe / ESBL risk)[1] | Carbapenem | 1 g IV every 8 h | 20 mg/kg every 8 h | Reserve for severe cholangitis, ESBL coverage, prior multi-resistant organism; renal dose adjustment |
Co-amoxiclav (community-acquired, mild)[1]
Aminopenicillin + beta-lactamase inhibitor
- Adult
- 1.2 g IV every 8 h; switch to oral 625 mg TDS once tolerating diet
- Paediatric
- Per local protocol
First-line for mild community-acquired cholecystitis without severity features; review at 48 h with cultures
Piperacillin-tazobactam[1]
Beta-lactam + beta-lactamase inhibitor
- Adult
- 4.5 g IV every 6–8 h
- Paediatric
- Per local protocol
Moderate-severe or healthcare-associated cholecystitis; broad gram-positive, gram-negative, anaerobic; renal dose adjustment
Ceftriaxone + metronidazole[1]
Third-generation cephalosporin + nitroimidazole
- Adult
- Ceftriaxone 1–2 g IV daily + metronidazole 500 mg IV every 8 h
- Paediatric
- Ceftriaxone 50–80 mg/kg/day; metronidazole 7.5 mg/kg every 8 h
Alternative for mild-moderate community-acquired; oral switch to cefuroxime + metronidazole when improving
Meropenem (severe / ESBL risk)[1]
Carbapenem
- Adult
- 1 g IV every 8 h
- Paediatric
- 20 mg/kg every 8 h
Reserve for severe cholangitis, ESBL coverage, prior multi-resistant organism; renal dose adjustment
Safety-net
- Severe abdominal pain, fever, vomiting, or yellowing eyes after a recent gallstone episode — same-day medical review[1]
- After cholecystectomy: most return to normal activity within 1–2 weeks; persistent jaundice, severe pain, fever, or worsening symptoms warrant review[1]
- Avoid high-fat meals during recovery; symptoms typically improve over weeks; bile-salt diarrhoea may settle with reduced fat intake[1]
Referral criteria
- All acute cholecystitisGeneral surgery for early laparoscopic cholecystectomy[1]
- Cholangitis or septic cholecystitisEmergency department with surgery and gastroenterology / interventional radiology[1]
- High-risk surgical candidate or grade III TG18 with severe organ dysfunctionTertiary HBP / interventional radiology for percutaneous cholecystostomy[1]
- Suspected choledocholithiasis with dilated CBD or raised LFTsGastroenterology / HBP for MRCP/EUS and ERCP planning[1]
Clinical summary
Diagnosis, antibiotic management, and timing of cholecystectomy for acute calculous cholecystitis in adults.
References
- 1.WSES Guidelines for Diagnosis and Treatment of Acute Calculous Cholecystitis (2020 update); Tokyo Guidelines TG18 for Acute Cholecystitis (2020)
- 2.2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World Journal of Emergency Surgery (2020)