REVIEW

CURRENT
OPINION Management of acute cholecystitis
Prabhava Bagla a, Juan C. Sarria a, and Taylor S. Riall b

Purpose of review
Various aspects of the management of acute calculous cholecystitis, including type and timing of surgery,
role of antibiotics, and nonoperative management, remain controversial. This review focuses on recently
published studies addressing the timing of cholecystectomy, use of cholecystostomy tubes, and role of
antibiotics in this condition.
Recent findings
In most cases, the diagnosis of acute cholecystitis can be initially confirmed with an abdominal ultrasound.
Early laparoscopic cholecystectomy (within 24–72 h of symptom onset) is better than delayed surgery (>7
days) for most patients with grade I and II diseases. Percutaneous cholecystostomy and novel endoscopic
gallbladder drainage interventions may be used as a temporizing measure or as definitive therapy in those
who are too sick to undergo surgery. Studies are conflicting as to whether antibiotics are required for the
treatment of uncomplicated cases.
Summary
Cholecystectomy remains the only definitive therapy for acute cholecystitis. Current guidelines recommend
treatment on the basis of disease severity at presentation. Antibiotics and a variety of minimally invasive
nonsurgical interventions, although not definitive, play an adjunctive role in the management of the
disease.
Keywords
acute cholecystitis, cholecystostomy, laparoscopic cholecystectomy

INTRODUCTION sensitivity and 81% specificity for ultrasound-

This review will focus on recent advances in the
diagnosis and treatment of acute calculous chole-
cystitis. Studies evaluating imaging modalities,
type and timing of surgery, gallbladder drainage
interventions in high-risk patients, and antibiotic
diagnosed acute cholecystitis.
Contrast-enhanced ultrasound is a newer
technique that may improve our ability to diagnose
gangrenous cholecystitis preoperatively. On con-
trast-enhanced ultrasound, areas without enhance-
&

therapy will be reviewed. Throughout the discus-
sion, the 2013 Tokyo Guidelines (TG13) for the
management of acute cholangitis and cholecystitis
grading system will be used to stratify severity of
illness (Table 1) [1].
ULTRASOUND
Currently, ultrasound is the recommended imaging
modality for the diagnosis of cholelithiasis and
acute cholecystitis. Typical diagnostic findings
include gallbladder wall thickening, pericholecystic
fluid, or a sonographic Murphy’s sign. Ultrasound
is relatively inexpensive, widely available, involves
no radiation exposure, and has high sensitivity,
specificity, and positive and negative predictive val-
ues for the diagnosis of cholelithiasis and acute
cholecystitis. In a meta-analysis of 26 studies involv-
ing 2847 patients, Kiewet et al. [2] reported 82%
ment correlate with ischemia. Ripollés et al. [3 ]
evaluated 109 patients who had both ultrasound
and contrast-enhanced ultrasound images and
underwent subsequent cholecystectomy. Images
were reviewed by three blinded radiologists and
correlated with histopathology. The sensitivity
was 85–91% and the specificity was 67–85% for
the diagnosis of gangrenous cholecystitis.
a
Division of Infectious Diseases, Department of Internal Medicine, Uni-
versity of Texas Medical Branch, Galveston, Texas and bDivision of
General Surgery and Surgical Oncology, Department of Surgery,
University of Arizona, Banner University Medical Center, Tucson, Arizona,
USA
Correspondence to Dr Prabhava Bagla, 301 University Boulevard, Route
0435, Galveston, TX 77555, USA. Tel: +1 409 747 0236; fax: +1 409
772 6527; e-mail: prabhava.bagla@gmail.com
Curr Opin Infect Dis 2016, 29:508–513
DOI:10.1097/QCO.0000000000000297

www.co-infectiousdiseases.com Volume 29  Number 5  October 2016

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

 Management of acute cholecystitis Bagla et al.

reported in another study 94% accuracy (169 out

KEY POINTS
 Ultrasound remains the preferred initial screening
modality for most patients with acute calculous
cholecystitis; HIDA and CT scans may be useful in
selected patients with suspected complications or to
exclude alternate diagnoses.
 Early laparoscopic cholecystectomy is the preferred
treatment for grade I disease.
 Cholecystostomy tube placement may be used as a
temporizing measure for severe grade II and
III diseases.
 Antibiotics play an adjunctive role in patients with
grade II–III diseases or sepsis. Short courses
are recommended.
Contrast-enhanced ultrasound is highly operator-
dependent and not widely available. Although con-
trast-enhanced ultrasound is a promising modality
for rapid identification of complicated cases and
avoids radiation exposure, the data supporting early
cholecystectomy in all cases of acute cholecystitis
may render such advanced imaging unnecessary.
As a result of the limited 24-h availability of
ultrasound in some hospitals, Hasani et al. [4] pro-
spectively assessed the role of bedside ultrasound
for the diagnosis of acute cholecystitis in the emer-
gency department. In this study, six emergency
physicians were enrolled in a 2-day course on ultra-
sound diagnosis. They performed and interpreted
ultrasound in 150 patients. Radiologists blinded
to the results subsequently performed formal ultra-
sound. Fourteen patients (9.3%) had acute chole-
cystitis. Of these, radiologists identified 12 out of the
14 patients and emergency physicians identified
five of the 14 patients when they performed the
initial test. This finding suggests that specialized
training is required for the evaluation of acute chol-
&
ecystitis. However, Gustafson et al. [5 ] recently
of 179 patients) of surgeon-performed bedside
ultrasound for the detection of gallstones.
HEPATOIMINO DIACETIC ACID SCAN
In cases of suspected acute cholecystitis with a non-
diagnostic initial ultrasound, hepatoimino diacetic
acid (HIDA) scan may provide a definitive diagnosis.
HIDA is performed by injecting intravenous radio-
active tracer that is excreted by the liver into the
biliary system, and then stored and excreted by
the gallbladder. Lack of visualization of the gallblad-
der indicates cystic duct obstruction and cholecys-
titis. Kaoutzanis et al. [6] compared HIDA with
ultrasound in 260 patients. HIDA had significantly
higher sensitivity (91 vs. 64%) and specificity (71 vs.
58%) than ultrasound for the diagnosis of acute
cholecystitis. Positive and negative predictive values
were also higher than those of ultrasound. Limita-
tions of HIDA include radiation exposure, inability
to exclude common bile duct obstruction, and time
for study completion. In our opinion, HIDA is rarely
necessary to confirm the diagnosis of acute chole-
cystitis in the setting of documented gallstones and
acute presentation, as cholecystectomy is indicated
regardless. HIDA is most useful in the setting of
high-risk surgical patients in whom the absence
of cholecystitis by HIDA would avoid an operation
associated with significant morbidity or mortality.
COMPUTED TOMOGRAPHY SCAN
Use of computed tomography (CT) scan has been
suggested when complications are suspected or
when other diagnoses are differentially diagnosed.
Fagenholz et al. [7] evaluated 101 patients with
operatively and pathologically confirmed acute
cholecystitis who underwent both CT and ultra-
sound preoperatively. CT was more sensitive than
ultrasound (92 vs. 79%) for acute cholecystitis; ultra-
sound was more sensitive than CT for cholelithiasis

Table 1. Criteria for the severity assessment of acute cholecystitis [1]

Grade I (mild) Grade II (moderate) Grade III (severe)

Does not meet the criteria of
grade III or grade II acute
cholecystitis; acute cholecystitis
in a healthy patient; no organ
dysfunction; mild inflammatory
changes in the gallbladder, and
making cholecystectomy a well
tolerated and low-risk operative
procedure
Associated with any of the following
conditions: white blood cell count
>18 000/mm3; palpable tender mass;
symptoms >72 h; marked local
inflammation: gangrenous
cholecystitis, pericholecystic abscess,
hepatic abscess, biliary peritonitis, or
emphysematous cholecystitis
Associated with any of the following organ
dysfunctions: cardiovascular: need for
dopamine 5 mg/kg or norepinephrine;
neurological: decreased consciousness;
respiratory: PaO2/FiO2 < 300; renal:
oliguria, creatinine >2.0 mg/dl; hepatic:
PT-INR > 1.5; hematological: platelets
<100 000/mm3

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Gastrointestinal infections
(87 vs. 60%), as a significant proportion of stones
are not radiopaque. Although CT may help rule out
other causes of intra-abdominal diseases, it should
not be the primary diagnostic modality for acute
cholecystitis given its low sensitivity and negative
predictive value for the presence of gallstones.
EARLY LAPAROSCOPIC
CHOLECYSTECTOMY
Removal of the gallbladder remains the only
definitive treatment for acute cholecystitis, with
laparoscopic cholecystectomy considered the gold
standard. Since the introduction of laparoscopic
cholecystectomy in the 1990s, the timing of chol-
ecystectomy in acute disease has been debated given
the clear benefits of the laparoscopic approach
coupled with increased difficulty and risk for
conversion-to-open when inflammation is severe.
Current literature supports early cholecystectomy
for acute cholecystitis. A 2013 Cochrane review of
randomized controlled trials by Gurusamy et al. [8]
compared 488 patients who underwent cholecystec-
tomy for less than 7 days vs. greater than 6 weeks
after onset of symptoms. There was no significant
difference in rates of conversion-to-open (early 19.7
vs. delayed 22.1%), postoperative complications
(early 6.5 vs. delayed 5.0%), or the incidence of bile
duct injuries (early 0.4 vs. delayed 0.9%) between
the groups. Similarly, a subsequent meta-analysis by
Menahem et al. [9] included nine randomized trials,
and 1220 patients supported these findings. The
mean hospital stay was lower in the early group,
with similar rates of bile duct injury.
In a large European multicenter trial, patients
were randomly assigned to undergo immediate
surgery within 24 h of admission vs. delayed laparo-
scopic cholecystectomy (N ¼ 314, 7–45 days) [10].
Patients who did not undergo immediate surgery
were treated with antibiotics for at least 48 h
(N ¼ 304). In the intent-to-treat analysis, conversion
rates were similar (9.9 in early group vs. 11.9% in
delayed group, P ¼ 0.44), and morbidity was lower in
the early group (11.6 vs. 34.4%). Total length of stay
was shorter in the early group (5.4 vs. 10.0 days),
corresponding to lower total hospital costs.
Two recent population-based studies have
addressed the timing of cholecystectomy. The obser-
vational design of these studies has the advantage
of large sample sizes and significant power, but is
subject to selection bias. de Mestral et al. [11] used
administrative claims data from Ontario to identify
22 202 patients with acute cholecystitis treated with
cholecystectomy. They used propensity score
matching to identify a matched cohort of 14 220
patients who underwent early (7 days, N ¼ 7110) or
510 www.co-infectiousdiseases.com
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delayed cholecystectomy (N ¼ 7110). The total
hospital length of stay was shorter in the early group
(mean difference 1.9 days). There were no signifi-
cant differences in conversion to open cholecystec-
tomy or mortality. The study reported a lower rate
of major bile duct injury (0.28 vs. 0.53%) in the
early group. Likewise, a French nationwide study
of 42 452 patients reported lower ICU admissions,
reoperation rates, and postoperative sepsis in
patients operated on between days 1–3 after admis-
sion compared with day 5 or later [12].
A recent meta-analysis of 77 case–control stud-
ies further evaluated optimal timing of laparoscopic
cholecystectomy in acute disease [13]. The authors
compared four groups: laparoscopic cholecystec-
tomy less than 72 h compared with more than
4 weeks, laparoscopic cholecystectomy less than
72 h compared with more than 72 h, laparoscopic
cholecystectomy less than 7 days (index admission)
compared with less than 4 weeks, and laparoscopic
cholecystectomy less than 7 days (index admission)
compared with less than 4 weeks. Laparoscopic
cholecystectomy less than 72 h was associated with
significant reductions in mortality, complications,
bile duct leaks, bile duct injuries, wound infections,
conversion rates, length of hospital stay, and blood
loss. In addition, although laparoscopic cholecys-
tectomy within the 72-h window was optimal,
patients operated after this window (within 7 days
on index admission) still benefited from early
surgery compared with delayed surgery.
Taken together, these data support the TG13
recommendation that patients with grade I acute
cholecystitis should undergo early cholecystectomy
[14]. As the above studies had inconsistent
definitions of ‘early’, controversy remains regarding
optimal timing, specifically within 24 h and
after 96 h.
SUBTOTAL CHOLECYSTECTOMY
Subtotal cholecystectomy involves piecemeal
dissection of the gallbladder, usually leaving behind
the posterior wall or part of the infundibulum.
Subtotal cholecystectomy is mostly done in the
setting of severe inflammation or fibrosis, which
limits the ability to safely dissect the triangle of
Calot. A recent meta-analysis evaluating 30 studies
with 1231 patients undergoing subtotal cholecys-
tectomy noted bile leak as the most common com-
plication, occurring in 42% of those without closure
and 16% of those with closure of the gallbladder or
&
cystic duct remnant [15 ]. Complications such as
hemorrhage, wound infection, and retained stones
were uncommon; mortality was 0.4%. Given that
the included studies were small, nonrandomized,
Volume 29  Number 5  October 2016

and subject to significant selection bias (patients
with the most severe inflammation and difficult
dissections had subtotal cholecystectomy), these
data suggest that subtotal cholecystectomy is a well
tolerated and effective alternative when total chol-
ecystectomy is not well tolerated.
CHOLECYSTOSTOMY TUBE PLACEMENT
Cholecystostomy tube placement performed percu-
taneously is considered an option under the TG13
for patients with grade II disease with symptoms
longer than 96 h and/or patients at high risk for
surgery, and in grade III disease as a temporizing
measure for all patients with planned, delayed chol-
ecystectomy [16]. However, these recommen-
dations are based on expert consensus and not
data-driven. A 2013 Cochrane review evaluated
studies comparing the following: first, the out-
comes of early vs. delayed cholecystectomy after
cholecystostomy and second, the outcomes of chol-
ecystostomy vs. conservative treatment [17]. Only
two randomized trials were identified and they
concluded that the role of cholecystostomy in
high-risk surgical patients with acute cholecystitis
is unclear and adequately powered trials with low
risk of bias are needed.
Chou et al. [18] investigated the optimal timing
of cholecystostomy and its relationship to clinical
outcomes in 209 patients with severe cholecystitis
that were not considered operative candidates.
When cholecystostomy was performed 24 h or less
from admission (N ¼ 109), there was a lower bleed-
ing rate (0.0 vs. 5.0%) and shorter hospital stay
(15.8 vs. 21 days) compared with the late chole-
cystostomy group (>24 h, N ¼ 100). Na et al. [19]
investigated the utility of preoperative cholecys-
tostomy in older patients with acute cholecystitis
with planned cholecystectomy during the index
admission. They noted lower rates of conversion
to open surgery in those patients who underwent
preoperative percutaneous gallbladder drainage
(12.8 vs. 32.5%). Mortality rates were similar
between the groups. Overall length of stay was
not affected by preoperative cholecystostomy.
However, the preoperative length of stay was
longer in the cholecystostomy group, implying a
shorter postoperative recovery time. In a study by
&
Bala et al. [20 ], 37% of 257 high-risk patients
required permanent cholecystostomy. Older age,
coronary artery disease, sepsis at presentation,
and elevated alkaline phosphatase were noted as
predictors of inability to provide definitive
treatment with cholecystectomy. Tube-related
complications occurred in 31% of patients, prim-
arily drain dislodgement.
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Management of acute cholecystitis Bagla et al.
ENDOSCOPIC INTERVENTIONS
Endoscopic transpapillary gallbladder drainage (ET-
GBD) and endoscopic ultrasound-guided-transmural
gallbladder drainage (EUS-TGBD) using a transgastric
or transduodenal puncture and drain or stent place-
ment have been suggested in patients in whom per-
cutaneous approaches are not anatomically feasible
(i.e., advanced liver disease, ascites, or coagulopathy).
Widmer et al. [21] reviewed 139 patients (45 with
malignant obstruction) who did not improve with
conservative measures. ET-GBD was initially
attempted, and if unsuccessful, EUS-TGBD was per-
formed. Overall the technical success rate was 92%.
Inoue et al. [22] assessed long-term outcomes in 64
high-risk surgical patients, who underwent ET-GBD
vs. percutaneous drainage. The technical success rate
of stenting was 83% in the acute setting and 94%
when reattempts were included. Cholecystitis recur-
rence rates were 17% in the percutaneous group and
0% in the endoscopic group. These data demonstrate
favorable long-term outcomes with endoscopic inter-
ventions in high-risk patients.
ANTIBIOTICS
Antibiotic therapy is recommended by the TG13
when immediate surgery is not going to be per-
formed (i.e., grade II disease with comorbidities or
long duration of symptoms and grade III disease)
[23]. A 2013 prospective study by Rodriguez-Sanjuan
et al. [24] evaluated surgical site infection rates with
different postoperative antibiotic courses (<4 days,
5–7 days, >7 days) in 287 patients after urgent
cholecystectomy for grade II disease. The authors
found no advantage of administering antibiotics
beyond 4 days on infection rates. Regimbeau et al.
&
[25 ] subsequently performed a randomized trial
evaluating the effect of postoperative antibiotics
on surgical site or distant infections at 4 weeks
following cholecystectomy in 414 patients with
grade I or II disease treated with preoperative amox-
icillin/clavulanic acid. Patients were then random-
ized to continued antibiotic postoperatively for
5 days or no continued antibiotic. No significant
differences in postoperative infection rates (17 vs.
15%) were found. These results support the practice
of discontinuing antibiotics the day after cholecys-
tectomy in these patients.
Although an association between positive bile
cultures (taken at the time of surgery) and postop-
erative complications has been suggested in patients
undergoing cholecystectomy for acute cholecystitis,
a recent study found no correlation between
positive bile cultures and disease severity or
outcomes [26]. Empiric regimens should target
Gram-negative organisms and anaerobes.
www.co-infectiousdiseases.com 511
Gastrointestinal infections
Commonly used agents include piperacillin/tazo-
bactam, cefoxitin, cefotaxime, or ceftriaxone with
metronidazole, and ciprofloxacin or levofloxacin
with metronidazole. No comparative studies have
demonstrated superiority of a given regimen over
the other. Local institutional antibiograms, poten-
tial toxicities, and cost should be considered on
regimen selection. Resistance rates in community-
& ultrasound in detecting gallstones: a validation study. World J Surg 2016;
acquired disease are still rare. Coccolini et al. [27 ]
recently evaluated 567 patients with acute cholecys-
titis from 116 centers in an international prospec-
tive cohort study. Out of 267 isolates identified, 21
(8%) were resistant (18 were extended-spectrum
beta lactamase or carbapenemase-producing
Gram-negative bacteria, two were methicillin-resist-
ant Staphylococcus aureus, and one was vancomycin-
resistant enterococcus). Emerging resistance in com-
munity-acquired infections is a concerning global
trend that may compromise available treatment
regimens in the future and strengthens the argu-
ment for limiting antibiotics where appropriate.
CONCLUSION
Patients presenting with clinical features suggestive
of acute cholecystitis should undergo abdominal
ultrasound to confirm the diagnosis. Other imaging
modalities (HIDA or CT scan) may be warranted if
the initial ultrasound is nondiagnostic or to exclude
complications or alternate diagnoses. The choice
and timing of intervention (laparoscopic cholecys-
tectomy vs. gallbladder drainage) depends upon the
severity of symptoms and the patient’s overall risk of
surgery. Drainage options include percutaneous
cholecystostomy and novel endoscopic approaches.
Studies are conflicting as to whether antibiotics are
routinely required for uncomplicated cases. Pro-
longed courses should be avoided.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Yokoe M, Takada T, Strasberg M, et al. TG13 diagnostic criteria and severity
grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci
2013; 20:35–46.
512 www.co-infectiousdiseases.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
2. Kiewet JJS, Leeuwenburgh MMN, Bipat S, et al. A systematic review and
meta-analysis of diagnostic performance of imaging in acute cholecystitis.
Radiology 2012; 264:708–720.
3. Ripollés T, Martı́nez-Pérez M, Martin G, et al. Usefulness of contrast-enhanced
& US in the diagnosis of acute gangrenous cholecystitis: a comparative study
with surgical and pathological findings. Eur J Radiol 2016; 85:31–38.
Largest study to date on the use of contrast-enhanced ultrasound for preoperative
diagnosis of gangenous cholecystitis.
4. Hasani SA, Fathi M, Daadpey M, et al. Accuracy of bedside emergency
physician performed ultrasound in diagnosing different causes of acute
abdominal pain: a prospective study. Clin Imaging 2015; 39:476–479.
5. Gustafson C, McNicholas A, Sonden A, et al. Accuracy of surgeon-performed
&
40:1688–1694.
This study noted that surgeons attempting ultrasound-based diagnosis of gall-
stones achieved good accuracy and correlation with radiologist-based ultrasound.
These results are in contrast with the study by Hasani et al. [4], wherein
nonradiologists were not found to be proficient at diagnosing cholecystitis.
Frequently, the distinction between grade I acute cholecystitis and acute biliary
colic is not clinically relevant as both conditions are best managed with laparo-
scopic cholecystectomy.
6. Kaoutzanis C, Davies E, Leichtle SW, et al. Is hepato-imino diacetic acid scan
a better imaging modality than abdominal ultrasound for diagnosing acute
cholecystitis? Am J Surg 2015; 210:473–482.
7. Fagenholz PJ, Fuentes E, Kaafarani H, et al. Computed tomography is more
sensitive than ultrasound for the diagnosis of acute cholecystitis. Surg Infect
(Larchmt) 2015; 16:509–512.
8. Gurusamy KS, Nagendran M, Davidson BR. Early versus delayed laparo-
scopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database
Syst Rev 2013; 9:CD010326.
9. Menahem B, Mulliri A, Fohlen A, et al. Delayed laparoscopic cholecystectomy
increases the total hospital stay compared to an early laparoscopic chole-
cystectomy after acute cholecystitis: an updated meta-analysis of randomized
controlled trials. HPB (Oxford) 2015; 17:857–862.
10. Gutt CN, Encke J, Koninger J, et al. Acute cholecystitis: early versus delayed
cholecystectomy, a multicenter randomized trial (ACDC study,
NCT00447304). Ann Surg 2013; 258:385–393.
11. de Mestral C, Rotstein OD, Laupacis A, et al. Comparative operative
outcomes of early and delayed cholecystectomy for acute cholecystitis:
a population-based propensity score analysis. Ann Surg 2014; 259:
10–15.
12. Polo M, Duclos A, Polazzi S, et al. Acute cholecystitis – optimal timing for early
cholecystectomy: a French Nationwide Study. J Gastrointest Surg 2015;
19:2003–2010.
13. Cao AM, Eslick GD, Cox MR. Early laparoscopic cholecystectomy is superior
to delayed acute cholecystitis: a meta-analysis of case-control studies. Surg
Endosc 2016; 30:1172–1182.
14. Yamashita Y, Takada T, Strasberg SM, et al. TG13 surgical management of
acute cholecystitis. J Hepatobiliary Pancreat Sci 2013; 20:89–96.
15. Elshaer M, Gravante G, Thomas K, et al. Subtotal cholecystectomy for ‘difficult
& gallbladders’ systematic review and meta-analysis. JAMA Surg 2015;
150:159–168.
This article summarizes all previous studies involving subtotal cholecystectomy.
Because patients who undergo this procedure by definition have complicated
anatomy, demonstration of long-term results comparable to those who underwent
regular laparoscopic cholecystectomy indicates that this procedure is safe and
effective.
16. Tsuyuguchi T, Itoi T, Takada T, et al. TG13 indications and techniques for
gallbladder drainage in acute cholecystitis (with videos). J Hepatobiliary
Pancreat Sci 2013; 20:81–88.
17. Gurusamy KS, Rossi M, Davidson BR. Percutaneous cholecystostomy for
high-risk surgical patients with acute calculous cholecystitis. Cochrane
Database Syst Rev 2013; 8:CD007088.
18. Chou CK, Lee KC, Chan CC, et al. Early percutaneous cholecystostomy in
severe acute cholecystitis reduces the complication rate and duration of
hospital stay. Medicine (Baltimore) 2015; 94:e1096.
19. Na BG, Yoo YS, Mun SP, et al. The safety and efficacy of percutaneous
transhepatic gallbladder drainage in elderly patients with acute cholecys-
titis before laparoscopic cholecystectomy. Ann Surg Treat Res 2015;
89:68–73.
20. Bala M, Mizrahi I, Mazeh H, et al. Percutaneous cholecystostomy is safe and
& effective option for acute calculous cholecystitis in select group of high-risk
patients. Eur J Trauma Emerg Surg 2015. [Epub ahead of print]
This study identified factors associated with need of permanent cholcystostomy in
high-risk patients. The most common complication of cholecystostomy when
patients are followed longitudinally is drain dislodgement.
21. Widmer J, Alvarez P, Sharaiha RZ, et al. Endoscopic gallbladder drainage for
acute cholecystitis. Clin Endosc 2015; 48:411–420.
22. Inoue T, Okumura F, Kachi K, et al. Long-term outcomes of endoscopic
gallbladder stenting in high-risk surgical patients with calculous cholecystitis
(with videos). Gastrointest Endosc 2016; 83:905–913.
23. Gomi H, Solomkin JS, Takada T, et al. TG13 antimicrobial therapy for acute
cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2013; 20:
60–70.
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24. Rodriguez-Sanjuan JC, Casella G, Antolin F, et al. How long is antibiotic
therapy necessary after urgent cholecystectomy for acute cholecystitis?
J Gastrointest Surg 2013; 17:1947–1952.
25. Regimbeau JM, Fuks D, Pautrat K, et al. Effect of postoperative antibiotic
& administration on postoperative infection following cholecystectomy for acute
calculous cholecystitis: a randomized clinical trial. JAMA 2014; 312:145–154.
Intravenous amoxicillin/clavulanate was used initially (this preparation is not
commercially available in the United States), and was converted to oral inake
when patients were able to eat. Postoperative antibiotic administration was not
beneficial.
0951-7375 Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Management of acute cholecystitis Bagla et al.
26. Cheng WC, Chiu YC, Chuang CH, Chen CY. Assessing clinical outcomes of
patients with acute calculous cholecystitis in addition to the Tokyo grading: a
retrospective study. Kaohsiung J Med Sci 2014; 30:459–465.
27. Coccolini F, Sartelli M, Catena F, et al. Antibiotic resistance pattern and
& clinical outcomes in acute cholecystitis: 567 consecutive worldwide patients
in a prospective cohort study. Int J Surg 2015; 21:32–37.
Gram-negative bacteria constituted 70% of the isolates, with Escherichia coli
isolated in 46% of the cases. Other bacteria isolated include Gram-positive
bacteria 24% (mostly enterococci), fungi 3%, and anaerobes 2.7%. Overall the
resistance rate was 8%.
www.co-infectiousdiseases.com 513