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Cholecystitis: Treatment & Medication
Updated: Aug 4, 2008
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Treatment
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:
- The current Sanford guide recommendations include piperacillin/tazobactam (Zosyn, 3.375 g IV q6h or 4.5 g IV q8h), ampicillin/sulbactam (Unasyn, 3 g IV q6h), or meropenem (Merrem, 1 g IV q8h). In severe life-threatening cases, the Sanford Guide recommends imipenem (500 mg IV q6h).
- Alternative regimens include a third-generation cephalosporin plus Flagyl (1 g IV loading dose followed by 500 mg IV q6h).
- 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. Recent studies have indicated that early laparoscopic cholecystectomy resulted in shorter total hospital stays with no significant difference in conversion rates or complications.6 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:
- High risk for general anesthesia
- Morbid obesity
- Signs of gallbladder perforation, such as abscess, peritonitis, or fistula
- Giant gallstones or suspected malignancy
- End-stage liver disease with portal hypertension and severe coagulopathy
Consultations
- Definitive therapy involves cholecystectomy or placement of a drainage device; therefore, consultation with a surgeon is warranted.
- Consultation with a gastroenterologist for consideration of ERCP may also be appropriate if concern exists of choledocholithiasis.
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.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
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.
Adult
12.5-25 mg PO/IV/IM/PR q4h prn
Pediatric
<2 years: Contraindicated
>2 years: 0.25-1 mg/kg PO/IV/IM/PR q4-6h prn
May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension
Documented hypersensitivity; <2 years (incidences of death due to respiratory depression)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma
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.
Adult
5-10 mg PO/IM tid/qid; not to exceed 40 mg/d
2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40 mg/d
25 mg PR bid
Pediatric
2.5 mg PO/PR q8h or 5 mg q12h prn; not to exceed 15 mg/d
IV dosing is not recommended for children
0.1-0.15 mg/kg/dose IM; change to PO as soon as possible
Coadministration with other CNS depressants or anticonvulsants may cause additive effects; coadministration with epinephrine may cause hypotension
Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Drug-induced Parkinson syndrome or pseudoparkinsonism occurs frequently; akathisia is the most common extrapyramidal reaction in elderly persons; lowers seizure threshold; caution in patients with history of seizures
Analgesics
Pain is a prominent feature of cholecystitis. 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.
Adult
50-150 mg PO/IV/IM/SC q3-4h prn
Pediatric
1-1.8 mg/kg (0.5-0.8 mg/lb) PO/IV/IM/SC q3-4h prn; not to exceed adult dose
Monitor for increased respiratory and CNS depression with coadministration of cimetidine; hydantoins may decrease effects; avoid with protease inhibitors
Documented hypersensitivity; MAOIs; upper airway obstruction or significant respiratory depression; during labor when delivery of premature infant is anticipated
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Category D in prolonged use or high doses at term; caution in patients with head injuries because may increase respiratory depression and CSF pressure (use only if absolutely necessary); use caution postoperatively and in patients with history of pulmonary disease (suppresses cough reflex); increased dosing levels, because of tolerance, may aggravate or cause seizures (even without prior history); adjust dose in patients with renal insufficiency (do not use in patients severe renal dysfunction); normeperidine metabolite accumulation may induce CNS toxicity; monitor closely for morphine-induced seizure activity if prior seizure history
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.
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate/dose or 5 doses/24 h
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; high-altitude cerebral edema (HACE); elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tab contains metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; caution in severe renal or hepatic dysfunction
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.
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone PO q4-6h prn
Phenothiazines may decrease analgesic effects; toxicity increases with coadministration of CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; not to exceed 4000 mg/24h of acetaminophen; higher doses may cause liver toxicity
Antibiotics
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 Unasyn, Zosyn for non–life-threatening cases of cholecystitis. In life-threatening cases, Sanford recommends Primaxin or meropenem. Alternatives include metronidazole plus a third-generation cephalosporin or Cipro or Aztreonam.
Ciprofloxacin (Cipro)
Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Has no activity against anaerobes. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared.
Adult
400 mg IV q12h
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Dosage adjustments (adult adjustments)
CrCl (mL/min) <10: 50% of PO or IV dose q12h
HD: 0.25-0.5 g PO or 0.2-0.4 g IV q12h
During peritoneal dialysis: 0.25-0.5 g PO or 0.2-0.4 g IV q8h
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Not drug of first choice in pediatrics due to increased incidence of adverse events compared to controls, including arthropathy; no data exist for dose for pediatric patients with renal impairment (ie, CrCl <50 mL/min)
Meropenem (Merrem)
Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.
Has slightly increased activity against gram-negatives and slightly decreased activity against staphylococci and streptococci compared to imipenem.
Adult
1 g IV q8h
Pediatric
60 mg/kg/d IV divided q8h
Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Dosage adjustments (adult adjustments):
CrCl (mL/min) 10-50: 0.5-1 g q12h
CrCl <10: 0.5 g/d
HD: As for CrCl <10, with an extra 0.5 g after HD
Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of medication
Imipenem and cilastatin (Primaxin)
For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated due to potential for toxicity.
Adult
Base initial dose on severity of infection, and administer in equally divided doses; dose may range from 250 to 500 mg q6h IV for a maximum of 3-4 g/d
Alternatively, 500-750 mg IM q12h or intra-abdominally
Pediatric
Infants >3 months and children <12 years: 15-25 mg/kg/dose IV q6h
Fully susceptible organisms: Not to exceed 2 g/d
Infections with moderately susceptible organisms: Not to exceed 4 g/d
>12 years: Administer as in adults
Coadministration with cyclosporine may increase CNS side effects of both agents; coadministration with ganciclovir may result in generalized seizures
Documented hypersensitivity; known hypersensitivity to amide local anesthetics; children with CNS infections (increased seizure risk); children <30 kg with renal impairment (lack of data)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal insufficiency (adult adjustments):
CrCl (mL/min) 80-50: 0.5 g q6-8h
CrCl 50-10: 0.5 g q8-12h
Hemodialysis (HD): 0.25-0.5 g after HD, then q12h
Adjust dose in renal insufficiency; avoid use in children <12 y with CNS infections
Caution with history of seizures, hypersensitivity to penicillins, cephalosporins, or other beta lactam antibiotics
Piperacillin and tazobactam (Zosyn)
Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.
Adult
3.375 g IV q6h
Pediatric
75 mg/kg IV q6h
Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels; high-dose parenteral penicillins may cause increased risk of bleeding
Documented hypersensitivity; treating severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis with a PO penicillin during acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBC counts before initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; caution in hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Ampicillin and sulbactam (Unasyn)
Drug combination of beta-lactamase inhibitor with ampicillin. Covers epidermal and enteric flora and anaerobes. Not ideal for nosocomial pathogens.
Adult
1.5 g (1 g ampicillin plus 0.5 g sulbactam) to 3 g (2 g ampicillin plus 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Pediatric
<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Metronidazole (Flagyl)
Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except Clostridium difficile enterocolitis).
Adult
Loading dose: 15 mg/kg or 1 g for 70-kg adult IV over 1 h
Maintenance dose: 6 h following loading dose, infuse 7.5 mg/kg or 500 mg for 70-kg adult over 1 h q6-8h; not to exceed 4 g/d
Pediatric
Administer as in adults
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
More on Cholecystitis |
| Overview: Cholecystitis |
| Differential Diagnoses & Workup: Cholecystitis |
 Treatment & Medication: Cholecystitis |
| Follow-up: Cholecystitis |
| Multimedia: Cholecystitis |
| References |
| « Previous Page | Next Page » |
References
Cullen JJ, Maes EB, Aggrawal S, et al. Effect of endotoxin on opossum gallbladder motility: a model of acalculous cholecystitis. Ann Surg. Aug 2000;232(2):202-7. [Medline].
Singer AJ, McCracken G, Henry MC, et al. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med. Sep 1996;28(3):267-72. [Medline].
Towfigh S, McFadden DW, Cortina GR, et al. Porcelain gallbladder is not associated with gallbladder carcinoma. Am Surg. Jan 2001;67(1):7-10. [Medline].
Sahai AV, Mauldin PD, Marsi V, et al. Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP. Gastrointest Endosc. Mar 1999;49(3 Pt 1):334-43. [Medline].
Lee SS, Park do H, Hwang CY, et al. EUS-guided transmural cholecystostomy as rescue management for acute cholecystitis in elderly or high-risk patients: a prospective feasibility study. Gastrointest Endosc. Nov 2007;66(5):1008-12. [Medline].
Siddiqui T, MacDonald A, Chong PS, et al. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis of randomized clinical trials. Am J Surg. Jan 2008;195(1):40-7. [Medline].
Bingener J, Schwesinger WH, Chopra S, et al. Does the correlation of acute cholecystitis on ultrasound and at surgery reflect a mirror image?. Am J Surg. Dec 2004;188(6):703-7.
Chiu HH, Chen CM, Mo LR. Emphysematous cholecystitis. Am J Surg. Sep 2004;188(3):325-6. [Medline].
Cox MR, Wilson TG, Luck AJ, et al. Laparoscopic cholecystectomy for acute inflammation of the gallbladder. Ann Surg. Nov 1993;218(5):630-4. [Medline].
Donovan JM. Physical and metabolic factors in gallstone pathogenesis. Gastroenterol Clin North Am. Mar 1999;28(1):75-97. [Medline].
Forbes LE, Bajaj M, McGinn T, et al. Perihepatic abscess formation in diabetes: a complication of silent gallstones. Am J Gastroenterol. Apr 1996;91(4):786-8. [Medline].
Greenwald JA, McMullen HF, Coppa GF, et al. Standardization of surgeon-controlled variables: impact on outcome in patients with acute cholecystitis. Ann Surg. Mar 2000;231(3):339-44. [Medline].
Gruber PJ, Silverman RA, Gottesfeld S, et al. Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med. Sep 1996;28(3):273-7. [Medline].
Jang T, Aubin C, Naunheim R. Minimum training for right upper quadrant ultrasonography. Am J Emerg Med. Oct 2004;22(6):439-43. [Medline].
Liolios A, Oropello JM, Benjamin E. Gastrointestinal complications in the intensive care unit. Clin Chest Med. Jun 1999;20(2):329-45, viii. [Medline].
Lo CM, Liu CL, Fan ST, et al. Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg. Apr 1998;227(4):461-7. [Medline].
McEvoy CF, Suchy FJ. Biliary tract disease in children. Pediatr Clin North Am. Feb 1996;43(1):75-98. [Medline].
Moscati RM. Cholelithiasis, cholecystitis, and pancreatitis. Emerg Med Clin North Am. Nov 1996;14(4):719-37. [Medline].
Roe J. Evidence-based emergency medicine. Clinical assessment of acute cholecystitis in adults. Ann Emerg Med. Jul 2006;48(1):101-3. [Medline].
Rosen CL, Brown DF, Chang Y, et al. Ultrasonography by emergency physicians in patients with suspected cholecystitis. Am J Emerg Med. Jan 2001;19(1):32-6. [Medline].
Rubens DJ. Hepatobiliary imaging and its pitfalls. Radiol Clin North Am. Mar 2004;42(2):257-78. [Medline].
Shah K, Wolfe RE. Hepatobiliary ultrasound. Emerg Med Clin North Am. Aug 2004;22(3):661-73, viii. [Medline].
Silberfein EJ, Zhou W, Kougias P, et al. Percutaneous cholecystostomy for acute cholecystitis in high-risk patients: experience of a surgeon-initiated interventional program. Am J Surg. Nov 2007;194(5):672-7. [Medline].
Sitzmann JV, Pitt HA, Steinborn PA, et al. Cholecystokinin prevents parenteral nutrition induced biliary sludge in humans. Surg Gynecol Obstet. Jan 1990;170(1):25-31. [Medline].
Yates MR 3rd, Baron TH. Biliary tract disease in pregnancy. Clin Liver Dis. 1999;3:131-147.
Further Reading
Keywords
cholecystitis, cholelithiasis, gallstones, gallbladder stones, gallbladder inflammation, cystic duct obstruction, cystic duct stones, acute cholecystitis, chronic cholecystitis, emphysematous cholecystitis, acalculous cholecystitis, calculous cholecystitis, stones in the cystic duct, obstruction of the cystic duct, biliary pain, acalculous biliary colic, calculous biliary colic, biliary stasis, cholecystectomy, sepsis, long-term total parenteral nutrition, long-term TPN, prolonged fasting, sickle cell disease, Salmonella infections, diabetes mellitus, cytomegalovirus, cryptosporidiosis, microsporidiosis infections, obesity, jaundice, major surgery, severe trauma, severe burns, myocardial infarction
