Acute cholecystitis usually subsides on a conservative regimen, including withholding oral feedings, intravenous alimentation, analgesics, and intravenous antibiotics (generally a second- or third-generation cephalosporin such as ceftriaxone 1 g intravenously every 24 hours, with the addition of metronidazole, 500 mg intravenously every 6 hours), although the need for antibiotics has been questioned in patients undergoing immediate cholecystectomy. In severe cases, a fluoroquinolone such as ciprofloxacin, 400 mg intravenously every 12 hours, plus metronidazole may be given. Morphine or meperidine may be administered for pain. Because of the high risk of recurrent attacks (up to 10% by 1 month and over 20% by 1 year), cholecystectomy—generally laparoscopically—should be performed within 24 hours of admission to the hospital for acute cholecystitis. Compared with delayed surgery, surgery within 24 hours is associated with a shorter length of stay, lower costs, and greater patient satisfaction. If nonsurgical treatment has been elected, the patient (especially if diabetic or elderly) must be watched carefully for recurrent symptoms, evidence of gangrene of the gallbladder, or cholangitis. In high-risk patients, ultrasound-guided aspiration of the gallbladder, if feasible, percutaneous or EUS-guided cholecystostomy, or endoscopic insertion of a stent or nasobiliary drain into the gallbladder may postpone or even avoid the need for surgery. Immediate cholecystectomy is mandatory when there is evidence of gangrene or perforation.
Surgical treatment of chronic cholecystitis is the same as for acute cholecystitis. If indicated, cholangiography can be performed during laparoscopic cholecystectomy. Choledocholithiasis can also be excluded by either preoperative or postoperative MRCP or ERCP.