RISK FACTORS:
β’ Cardiac surgery
β’ Trauma
β’ Biliary parasites
β’ Gallstones
β’ Rapid weight loss
β’ Prolonged parenteral alimentation
β’ Pregnancy
Medical Care: For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, analgesia, and intravenous antibiotics. For mild cases of acute cholecystitis, antibiotic therapy with a single broad-spectrum antibiotic is adequate. Some options include the following:
" Current Sanford guide recommendations include ampicillin (4-6 g/d), ampicillin/sulbactam (Unasyn, 3 g IV/IM q6h), or piperacillin/tazobactam (Zosyn, 3.375 g IV q6h). (In severe life-threatening cases, the Sanford Guide also recommends Primaxin or meropenem.)
" For severe cases of acute cholecystitis, gentamicin (3-5 mg/kg/d) with clindamycin (1.8-2.7 g/d) or metronidazole with a third-generation cephalosporin provides adequate coverage.
" Bacteria that are commonly associated with cholecystitis include E coli and Bacteroides fragilis and Klebsiella, Enterococcus, and Pseudomonas species.
" Emesis can be treated with antiemetics and nasogastric suction.
" Because of the rapid progression of acute acalculous cholecystitis to gangrene and perforation, early recognition and intervention are required.
" Supportive medical care should include restoration of hemodynamic stability and antibiotic coverage for gram-negative enteric flora and anaerobes if biliary tract infection is suspected.
" Daily stimulation of gallbladder contraction with intravenous CCK has been shown by some to effectively prevent the formation of gallbladder sludge in patients receiving TPN.
Surgical Care: Laparoscopic cholecystectomy is the standard of care for the surgical treatment of cholecystitis. Surgery is usually performed after symptoms have subsided but during the hospitalization for acute illness. For elective laparoscopic cholecystectomy, the rate of conversion from a laparoscopic procedure to an open surgical procedure is approximately 5%. The conversion rate for emergency cholecystectomy where perforation or gangrene is present may be as high as 30%.
" Immediate cholecystectomy or cholecystotomy is usually reserved for complicated cases in which the patient has gangrene or perforation.
" Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients treated by surgeons with adequate experience in laparoscopic cholecystectomy.
" For patients at high surgical risk, placement of a sonographically guided, percutaneous, transhepatic cholecystostomy drainage tube coupled with the administration of antibiotics may provide definitive therapy.
" Results of studies suggest that most patients with acute acalculous cholecystitis can be treated with percutaneous drainage alone.
" Contraindications for laparoscopic cholecystectomy include the following:
o High risk for general anesthesia
o Morbid obesity
o Signs of gallbladder perforation such as abscess, peritonitis, or fistula
o Giant gallstones or suspected malignancy
o End-stage liver disease with portal hypertension and severe coagulopathy
Diet: Patients admitted for cholecystitis should receive nothing by mouth (NPO) because of expectant surgery. However, in uncomplicated cholecystitis, a liquid or low-fat diet may be appropriate until the time of surgery.
PATIENT MONITORING : Post cholecystectomy - follow through postoperative period
PREVENTION/AVOIDANCE:
β’ Avoid risk factors when possible
β’ During rapid weight loss following bariatric surgery or very low calorie diets, ursodeoxycholic acid (ursodiol)10
mg/kg/day
β’ During total parenteral alimentation for more than one month, daily ingestion of 100 kcal, or injection of
cholecystokinin
POSSIBLE COMPLICATIONS :
Occur in about 5% cases of acute cholecystitis and include - perforation, abscess formation, fistula
formation (intestine, colon, cutaneous), gangrene, empyema, cholangitis, hepatitis, pancreatitis, gallstone
ileus, carcinoma
EXPECTED COURSE/PROGNOSIS :
β’ In general the prognosis is good for gallbladder disease. Those who die during acute episodes are mainly
due to other conditions, especially coronary artery disease.
β’ Symptomatic gallstones usually have recurrent symptoms in 3 to 6 months indicating need for future action
β’ After cholecystectomy, stones may recur in bile ducts