In approximately 75% of cases, acute calculous cholecystitis will subside with conservative therapy, which consists of maintenance of a fasting state, intravenous fluid hydration, and analgesia. Although acute calculous cholecystitis is primarily an inflammatory process, secondary bacterial infection of the gallbladder can occur, particularly when complications ensue. The organisms found in the biliary tract in these instances are typically the same as normal intestinal flora. Empiric antimicrobial therapy should be directed at these organisms. When the results of antimicrobial susceptibility testing become available, more specific antibiotic therapy should be substituted. Antibiotics are typically not required for the treatment of uncomplicated cholecystitis, since they do not appear to affect the outcome of the attack or decrease the incidence of local infectious complications.

The selection and timing of surgical intervention depend on the severity of symptoms and the patient’s overall risk of surgery. Surgical intervention should be considered in patients with a known or suspected complication (gangrene, pericholecystic abscess, perforation with peritonitis) or in those with intractable pain and progressive fever despite supportive therapy. Consultation with a general surgeon should be obtained to assist in the selection of definitive therapy. Although open cholecystectomy had been considered the gold standard for the treatment of acute calculous cholecystitis, laparoscopic cholecystectomy has become the operative procedure of choice. In unstable patients in whom surgical intervention is contraindicated, drainage of the gallbladder may be performed with an ultrasound- guided percutaneous cholecystostomy. This involves placing a catheter into the gallbladder with the patient under local anesthesia. Complications include bacteremia, bleeding, and peritonitis due to bile leak.

*103/348/5*