Acute Cholecystitis.

Patients with a diagnosis of acute cholecystitis need to be hospitalized, with surgery (ie, cholecystectomy) being the treatment of choice. While hospitalized, they should be treated with intravenous hydration and with intravenous antibiotics covering enteric organisms. They should receive nothing by mouth and may require a nasogastric tube if ileus is present. The use of such conservative management for 24 to 48 hours allows the inflammatory and infectious processes to "cool down." Early surgery performed right after this initial period of conservative therapy is preferred over delayed surgical management (ie, discharge of the patient and readmission for the surgery 6 to 8 weeks later). Several studies have shown that early cholecystectomy not only has no adverse effects on complication rates but also leads to shorter hospital stays and quicker return to productivity. Laparoscopic cholecystectomy is the preferred operation because it is associated with a shorter hospital stay, less pain, and earlier return to productivity than is open cholecystectomy. There is an increase in the frequency of bile duct injury with this procedure, however. In patients who are poor surgical candidates, cholecystostomy can be performed via percutaneous catheter drainage of the gallbladder with the patient under local anesthesia. In addition, endoscopic transpapillary drainage with or without gallstone dissolution (methyl tert-butyl ether ) has been demonstrated to be an effective alternative to surgery in high-risk patients with acute calculous cholecystitis.