eMedicine Specialties > Emergency Medicine > Gastrointestinal

Cholecystitis and Biliary Colic: Treatment & Medication

Author: Rahul Sharma, MD, MBA, FACEP, Assistant Professor, Weill Medical College of Cornell University; Attending Physician, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Coauthor(s): Peter A D Steel, MA, MBBS, Staff Physician, Department of Emergency Medicine, Joan and Sanford I Weill Medical College of Cornell and Columbia University College of Physicians and Surgeons, New York Presbyterian Hospitals
Contributor Information and Disclosures

Updated: Jul 28, 2009

Treatment

Prehospital Care

• Patients with gallbladder colic or cholecystitis usually present in the prehospital setting with severe abdominal pain. Transport patients with minor symptoms to the hospital with an IV in place and monitor. However, the diagnosis of cholecystitis is not a prehospital diagnosis.
• In patients with severe pain (eg, differential includes abdominal aortic aneurysm, myocardial infarction) and in patients with hypotension and/or fever who may have cholecystitis or cholangitis, prehospital care should include the following:
  • As with all emergencies, airway, breathing, and circulation take priority and should be assessed immediately.
  • Monitoring (pulse oximetry, cardiac monitor, frequent blood pressure measurements, blood glucose measurement)
  • Stabilization (oxygen, placement of 2 large-bore IVs, administration of IV fluids to unstable patients)
  • Rapid transport

Emergency Department Care

• Primary goal of ED care is stabilization of the patient and an expedient diagnosis.
• Suspect gallbladder colic in patients with less than 4-6 hours of right upper quadrant pain that radiates to the back. Consider acute uncomplicated cholecystitis in patients with pain of longer duration and with or without low-grade fever. Severe cholecystitis can develop into sepsis or cholangitis, especially in patients with diabetes or elderly patients, in whom the diagnosis may be delayed.
• After assessment of the ABCs, perform the standard opening gambit of IV, pulse oximetry, oxygen, ECG, and monitoring. Send labs when the IV is placed; include blood cultures if the patient is febrile.
• Replace volume loss with normal saline, then maintenance fluids. Make patients nothing by mouth (NPO). Nasogastric suction may be needed in patients with persistent vomiting or abdominal distention.
• In patients who are unstable or have severe pain, consider a bedside ultrasound to exclude an abdominal aortic aneurysm and assist in the diagnosis of cholecystitis.
• In 2007, the unvalidated "Tokyo guidelines" were published, a set of clinical and radiological diagnostic criteria for acute cholecystitis. Patients exhibiting one of the local signs of inflammation, such as Murphy's sign, or a mass/pain/tenderness in the right upper quadrant, as well as one of the systemic signs of inflammation, such as fever, elevated white blood cell count, and elevated C-reactive protein level, are diagnosed as having acute cholecystitis. Imaging findings characteristic of acute cholecystitis confirm the diagnosis.⁶
• Once diagnosis of acute cholecystitis is made, it usually is treated by hospitalization. This may include medical and/or surgical therapy. Some patients may be treated as outpatients.
• The guidelines of the Infectious Diseases Society of America recommend that antimicrobial therapy be instituted if infection is suspected on the basis of laboratory and clinical findings (>12,500 WCC; temp >38.5°C) and radiographic findings (eg, air in the gallbladder or gallbladder wall).⁷
• Antibiotics are also recommended for routine use in patients who are elderly or have diabetes or immunodeficiency and for prophylaxis in patients undergoing cholecystectomy to reduce septic complications even when infection is not suspected.⁸
• Pain control considerations are as follows:
  • Several studies now have shown that early pain control in ED patients with abdominal pain does not hinder the diagnosis. Therefore, administer pain control early, without waiting for the diagnosis or surgical consult. A courtesy call to the surgical consultant prior to administration of narcotics offers the expedient opportunity to examine the patients without narcotics, which occasionally diminishes surgical resistance to prediagnosis narcotic use.
  • Pain control should be with opiate analgesics such as meperidine (Demerol). Morphine is generally not recommended since it can increase the tone of the sphincter of Oddi.
  • Anticholinergic antispasmodics, such as dicyclomine (Bentyl), are also recommended in the initial management of acute biliary colic and cholecystitis.
  • Anti-inflammatory medications such as ketorolac or indomethacin have been reported to be effective in relieving pain from gallbladder distention. Because the release of prostaglandins results in gallbladder distension, inhibition of these prostaglandins may help alleviate some of the symptoms. However, they may not be as effective when biliary colic is complicated by infection.
  • Antiemetics such as metoclopramide or prochlorperazine can be used.

Consultations

• Historically, cholecystitis was operated on emergently, resulting in increased mortality. Currently, practice is to cool off the gallbladder and perform a cholecystectomy after several days or readmit the patient at a later date.
• Emergent cholecystectomy is usually performed in 20% of cases of acute cholecystitis that has become complicated (ie, gangrene, perforation).
• In high surgical risk patients, placement of a percutaneous cholecystostomy is an acceptable alternative and can be performed at the bedside with ultrasound guidance.
• Prescribe an urgent gastroenterology consultation for ERCP for patients with evidence of choledocholithiasis (ie, common bile duct stones seen on sonography, dilated common bile ducts, elevated LFTs, pancreatitis).
• Surgical consult is appropriate, and depending on the institution, either medicine or surgery may admit the patient for conservative care.

Medication

Although surgical therapy is treatment of choice for acute cholecystitis, many patients require hospitalization for stabilization and "cooling off" of the gallbladder prior to surgery. Indications for urgent surgical intervention include patients with complications such as empyema, emphysematous cholecystitis, or perforation. Medical therapy of gallbladder colic includes antiemetics and pain control. In mild cholecystitis, in which inflammation is the primary process, antibiotics are prophylactic but usually are used. In acute cholecystitis, broad-spectrum antibiotic coverage is used.

The following dosages are general recommendations. Please check current sources prior to administration.

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 at parasympathetic sites.

Analgesics

When dicyclomine (Bentyl) is not effective, a narcotic is appropriate. The narcotic of choice is meperidine due to potential problems of increased tone of sphincter of Oddi with morphine.

Meperidine (Demerol)

Narcotic analgesic with multiple actions similar to those of morphine. However, may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.

Antiemetics

Cholecystitis and particularly obstruction of common bile duct can cause nausea and vomiting; therefore, antiemetics can be helpful.

Promethazine HCl (Phenergan, Anergan, Prorex)

Antidopaminergic agent effective in treatment of emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.

Prochlorperazine (Compazine)

Antidopaminergic drug that blocks postsynaptic mesolimbic dopamine receptors, has anticholinergic effect, and can depress reticular activating system, possibly responsible for relieving nausea and vomiting.

Antibiotics

Treatment of acute cholecystitis usually requires single-agent therapy, but for more serious infections, combination drug treatment has increased broad-spectrum coverage. Debate exists as to whether the most effective antibiotics must have high biliary concentrations. Antibiotics should be guided to target the most common organisms found in biliary tract pathology. These include E coli, Klebsiella species, and Streptococcus species.

Single-agent regimens include the following: piperacillin and tazobactam, ampicillin and sulbactam, mezlocillin, imipenem, meropenem, ticarcillin, and clavulanate.

Good combinations include the following: penicillin (including piperacillin, ampicillin, or penicillin) and metronidazole; the above plus an aminoglycoside (gentamicin or tobramycin); and aminoglycoside and third-generation cephalosporin.

Piperacillin/tazobactam (Zosyn)

Drug combination usually used in combination therapy. Antibiotic regimen needs to cover enteric microbes, including most common organisms: E coli (39%), Klebsiella species (54%), Enterobacter (34%), enterococci (34%), and group D streptococci.

Mezlocillin (Mezlin)

During growth phase, interferes with bacterial cell wall synthesis, causing death in susceptible microorganisms. Has antipseudomonal activity.

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. Reserve for very ill patients. May be used alone or in combination.

Cefoxitin (Mefoxin)

Second-generation cephalosporin indicated for management of infections caused by susceptible gram-positive cocci and gram-negative rods. Many infections caused by gram-negative bacteria, resistant to some cephalosporins and penicillins, respond to cefoxitin.

Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes.
Single daily dosing has not been well studied in cholangitis. Do not use if evidence of renal insufficiency exists.

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