What are the current guidelines for the management of mild versus severe cholecystitis in adults?

Management of Mild Cholecystitis: Mild acute cholecystitis typically requires hospital admission for confirmation of diagnosis through abdominal ultrasound and blood tests, monitoring of vital signs, and initiation of treatment including intravenous fluids, antibiotics, and analgesia. Early laparoscopic cholecystectomy is recommended to be performed within 1 week of diagnosis to prevent complications and resolve inflammation. If surgery is contraindicated or the patient is unfit, conservative management with antibiotics and supportive care is provided, with consideration of percutaneous cholecystostomy if conservative treatment fails or gallbladder empyema develops.

Management of Severe Cholecystitis: Severe acute cholecystitis, often associated with systemic signs of infection or complications such as necrosis, abscess, or perforation, requires urgent hospital admission and close monitoring of respiratory and hemodynamic status. Early surgical assessment is critical, with laparoscopic cholecystectomy as the treatment of choice when feasible. In critically ill patients or those with contraindications to surgery, percutaneous cholecystostomy is recommended as a temporizing measure. Mortality rates are higher in severe cases, especially acalculous cholecystitis with gangrene or perforation, necessitating prompt and aggressive management.

In all cases, analgesia should be optimized, with NSAIDs like diclofenac preferred for pain control unless contraindicated, and opioids considered if NSAIDs are insufficient. Patients should be advised on dietary modifications such as a low-fat diet to reduce biliary pain while awaiting surgery.

Referral to secondary care and surgical services with expertise in biliary disease is essential for both mild and severe cases to ensure appropriate diagnostic workup and timely intervention.

These recommendations align with the NICE guideline on gallstone disease, the Tokyo guidelines (TG13), the Association of Upper Gastrointestinal Surgeons (AUGIS), and the World Society of Emergency Surgery (WSES) guidelines.