Acute cholecystitis: Severity assessment and management

Abstract

Acute cholecystitis is one of the commonest biliary tract emergency. Early diagnosis and prompt treatment is essential to reduce the morbidity and mortality associated with the disease. Assessment of the severity of the disease is essential to develop a safe therapeutic plan for the patient. The Tokyo guidelines (TG 18/TG 13) provides a lucid system for grading the severity of acute cholecystitis. Supportive care, antibiotic therapy followed by early laparoscopic cholecystectomy is the mainstay of treatment. Fitness to undergo surgery is determined by the Charlson Comorbidity Index and the American College of Anaesthesiologist’s physical status examination. Those unfit for surgery are best treated by early biliary drainage followed by delayed cholecystectomy. The incidence of iatrogenic bile duct injury is high in severe cases. A low threshold for conversion to open cholecystectomy is essential in such cases to prevent iatrogenic biliovascular injuries. A holistic clinical approach comprising of establishing the diagnosis, grading the severity of acute cholecystitis, assessment of fitness to undergo surgery, administration of supportive care and antibiotics followed by early cholecystectomy constitutes a safe surgical approach to acute cholecystitis.