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MEDICAL MANAGEMENT OF
CHOLECYSTITIS
NARCISO A. CAIBAN
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CHOLECYSTITIS:
1. Initial treatment includes bowel rest: NPO
2. Intravenous hydration
3. Pharmacotherapy
> antiemetics
> anticholinergics
> analgesics
> antibiotics
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DIET
Patients admitted for cholecystitisshould receive nothing by
mouth (NPO)
and the insertion of nasogastric tube
for evacuation of gastric contents (to
eliminate unnecessary stimulation tothe biliary system and to
reduce
infectious exposure). However, in
uncomplicated cholecystitis, a liquid
or low-fat diet may be appropriate
until the time of surgery.
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IV therapy
Administer intravenous
(IV) fluids to correct anydehydration and continue
as maintenance therapy.
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Pharmacotherapy:
ANTIEMETICS
Patients with cholecystitis frequently experience associated
nausea and vomiting. Antiemetics can help to make the patient
more
comfortable and can prevent fluid and electrolyte
abnormalities.
Promethazine (Phenergan, Prorex, Anergan)For symptomatic
treatment of nausea in vestibular dysfunction.
Antidopaminergic agent effective in treating emesis. Blocks
postsynaptic
mesolimbic dopaminergic receptors in brain and reduces stimuli
to
brainstem reticular system.
Prochlorperazine (Compazine)
May relieve nausea and vomiting by blocking postsynaptic
mesolimbic dopamine receptors through anticholinergic effects
and
depressing reticular activating system. In addition to
antiemetic effects, it
has the advantage of augmenting hypoxic ventilatory response,
acting as a
respiratory stimulant at high altitude.
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ANALGESICS
Pain is a prominent feature of cholecystitis. Several studies
now have
shown that early pain control in patients with abdominal pain
does not
hinder the diagnosis. Therefore, administer pain control early,
without
waiting for the diagnosis or surgical consult. Classic teaching
is that
morphine is not the agent of choice because of the possibility
of increasing
tone at the sphincter of Oddi. Meperidine has been shown to
provide
adequate analgesia without affecting the sphincter of Oddi and,
therefore,
is the DOC.
Meperidine (Demerol)
DOC. Analgesic with multiple actions similar to those of
morphine.
May produce less constipation, smooth muscle spasm, and
depression of
cough reflex than similar analgesic doses of morphine.
Hydrocodone and acetaminophen (Vicodin, Lortab 5/500,
Lorcet-HD)Drug combination indicated for moderate to severe
pain.
Each tab/cap contains 5 mg hydrocodone and 500 mg
acetaminophen.
Oxycodone and acetaminophen (Percocet, Tylox, Roxicet)
Drug combination indicated for relief of moderate to severe
pain.
Each tab/cap contains 5 mg oxycodone and 325 mg
acetaminophen.
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ANTIBIOTICS
The guidelines of the Infectious Diseases Society of America
recommend that
antimicrobial therapy be instituted if infection is suspected on
the basis oflaboratory and clinical findings (>12,500 white
cells per cubic millimeter; temp
>38.5C) and radiographic findings (eg, air in the gallbladder
or gallbladder
wall).
Treatment of cholecystitis with antibiotics should provide
coverage against the
most common organisms, including E coli, B fragilis, and
Klebsiella,
Pseudomonas, and Enterococcus species. Current Sanford guide
recommendations for the treatment of cholecystitis include:
nonlife-threatening cases:
Unasyn (Ampicillin and Sulbactam), Zosyn (Piperacillin and
Tazobactam)
life-threatening cases:
Primaxin (Imipenem and Cilastatin)or meropenem. Alternatives
include
metronidazole plus a third-generation cephalosporin or Cipro or
Aztreonam.
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Anticholinergics
Antispasmodics and anticholinergics are thought to decrease
gallbladder and biliary tree tone, which decreases pain
associated with
gallstones.
Dicyclomine hydrochloride (Bentyl)
Has antimuscarinic and anticholinergic effects on smooth
muscle.
Moderately effective in reducing pain of gallbladder colic and
cholecystitis.Used in many institutions as first-line pain control
for this disease, with
narcotics as second-line pain controllers. May not be given
IV.
Glycopyrrolate (Robinul)
Use similarly to dicyclomine for anticholinergic effects. Acts
in smooth
muscle, CNS, and secretory glands, where blocks action of
acetylcholine atparasympathetic sites.
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Antibiotics are also recommended for
routine use in patients who are elderly or
have diabetes or immunodeficiency and forprophylaxis in patients
undergoing
cholecystectomy to reduce septic
complications even when infection is not
suspected. In a randomized trial of the use
of cefamandole in patients with acute
cholecystitis who underwent opencholecystectomy, a short course
(three
doses) was as effective as a 7-day course.
The first dose of an antibiotic should be
given within 1 hour before
cholecystectomy. It is advisable to culture
the gallbladder bile at the time of surgery toguide the
selection of antibiotics in the
event that postoperative septic
complications shouldarise.
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THANK YOU
