Medication Summary
Surgical intervention is the definitive treatment for cholecystitis, especially in the pediatric population. However, bile acids have been used with some success for the dissolution of cholesterol gallstones.
Gallstone Solubilizing Agents
Class Summary
Gallstone solubilizing agents are used for the medical dissolution of cholesterol gallstones. Ursodiol and chenodiol are orphan drugs that have been approved by the FDA for gallstone dissolution; however, these agents have not been FDA approved yet for children.
Ursodiol (Actigall, Urso)
Ursodiol suppresses hepatic synthesis and secretion and intestinal absorption of cholesterol. It does not seem to significantly inhibit synthesis and secretion of endogenous bile acids or affect secretion of phospholipids into bile.
Overall, ursodiol increases the concentration at which cholesterol saturation occurs and allows cholesterol to solubilize in an aqueous medium. It is preferred over chenodiol because of its relative safety.
Chenodiol (Chenix)
Chenodiol acts in a similar fashion to ursodiol; however, its metabolite lithocholic acid is hepatotoxic and may cause hepatobiliary damage itself. Chenodiol given at low doses (< 10 mg/kg/d) may actually increase the rate of cholecystectomy. Because of these effects, ursodiol is preferred.
Antibiotics
Class Summary
Antibiotics with biliary excretion covering enteric pathogens may be administered to control infection. The combination of ampicillin, gentamicin, and clindamycin has been a common and well-accepted regimen. More recently, additional antimicrobial agents, including piperacillin-tazobactam and second-generation and third-generation cephalosporins, have been recommended when antibiotic treatment is indicated. The choice of agent depends, importantly, on whether the presumptive bacterial infection is acquired in the community or the healthcare facility.
The use of antibiotics remains controversial, and much of the available data regarding antimicrobial usage derive from studies in adults. These reports generally agree that antibiotics are not necessary in simple cases and should be reserved for persistent fever or worsening of the condition.
Ampicillin
Ampicillin is a broad-spectrum penicillin. It interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.
Gentamicin
Gentamicin is an aminoglycoside antibiotic for gram-negative bacteria, including Pseudomonas species. It is synergistic with beta-lactamase against enterococci. It interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.
Clindamycin (Cleocin)
Clindamycin is a semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. It inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. It distributes widely in the body, without penetration of the CNS. It is protein bound and excreted by the liver and kidneys. It is effective against gram-positive aerobic and anaerobic bacteria (except enterococci).
Antibiotic
Piperacillin/tazobactam (Zosyn)
Piperacillin-tazobactam is a combination antimicrobial drug comprising the penicillin analogue piperacillin and the β-lactamase inhibitor tazobactam. This combination has activity against a broad spectrum both of Gram-positive and Gram-negative organisms as well as Pseudomonas aeruginosa.
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Pediatric Cholecystitis. Diagram illustrating the technique for laparoscopic cholecystectomy. The gallbladder is retracted with grasping 5-mm laparoscopic instruments, and clips are applied over the cystic duct and artery.
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Pediatric Cholecystitis. Photograph of a gallbladder filled with numerous small cholesterol stones.
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Pediatric Cholecystitis. Operative photograph illustrating the position of small (5 mm, 10 mm) trocars in the abdomen of a 12-year-old child undergoing laparoscopic cholecystectomy. By using this technique, the surgeon can avoid large incisions and remove the gallbladder safely.
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Pediatric Cholecystitis. Photograph illustrating the role of endoscopic retrieval of common bile duct stones. The picture shows a balloon placed via the endoscope into the ampulla for extraction of a cholesterol stone that was occluding the common bile duct.
Tables
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- Overview
- Presentation
- DDx
- Workup
- Approach Considerations
- Laboratory Studies
- Plain Abdominal Radiography
- Abdominal Ultrasonography
- Oral Cystography
- Biliary Scintography
- Magnetic Resonance Cholangiopancreatography
- Endoscopic Retrograde Cholangiopancreatography
- Endoscopic Ultrasonography
- Cholecystokinin Stimulation
- Histologic Findings
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- Treatment
- Guidelines
- Medication
- Media Gallery
- References
