Acute cholecystitis - Treatment

Indications for hospitalization

All patients with acute cholecystitis are subject to hospitalization in the surgical department.

Indications for specialist consultation

Acute cholecystitis is always an indication for consultation with a surgeon. If acute cholecystitis occurs against the background of severe pathology, the patient is observed by specialists of the corresponding profile.

Goals of treatment of acute cholecystitis

• Prevention of the development of complications and legal outcome, for which it is first necessary to promptly resolve the issue of surgical treatment of acute cholecystitis.
• Reducing the severity of the inflammatory process - antibacterial therapy, anti-inflammatory drugs.
• Symptomatic treatment: pain relief, restoration of water and electrolyte balance.

Non-drug treatment of acute cholecystitis

Mode

Bed.

Diet

A necessary component of conservative therapy for acute cholecystitis is fasting.

Drug therapy for acute cholecystitis

In acute cholecystitis of any severity, conservative therapy with antibacterial, anti-inflammatory and detoxifying agents should be initiated.

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Antibiotics for acute cholecystitis

The advisability of antibacterial therapy in all cases of acute cholecystitis, although it remains questionable, is recognized by the majority of leading specialists.

Antibiotics are administered to treat septicemia, prevent peritonitis and empyema of the gallbladder. In the first 24 hours of the disease, sowing of the gallbladder contents gives an increase in microflora in 30% of patients, after 72 hours - in 80%.

Escherichia coli, Streptococcus faecalis and Klebsiella spp. or their combinations are most often isolated. Anaerobes such as Bacteroides spp. and Clostridia spp., which usually coexist with aerobes, may be found.

The choice of drug depends on the type of pathogen detected during bile culture, its sensitivity to antibiotics, and the ability of the antibacterial drug to penetrate into the bile and accumulate in it. The duration of antibiotic treatment is 7-10 days. Intravenous administration of drugs is preferable. The following drugs are prescribed: amoxicillin + clavulanate, cefoperazone, cefotaxime, neftriaxone, cefuroxime. Cephalosporins of the second and third generations are combined with metronidazole if necessary.

Alternative option: ampicillin 2 g IV every 6 hours + gentamicin IV + metronidazole 500 mg IV every 6 hours (the most effective combination with a broad spectrum of antimicrobial action). It is also possible to use ciprofloxacin (including in combination with metronidazole).

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Pain relief and anti-inflammatory therapy

Additionally, anti-inflammatory drugs are prescribed and, if necessary, narcotic analgesics: diclofenac in a single dose of 75 mg (analgesic effect, prevention of progression of biliary colic);

Meperidine (narcotic analgesic) at a dose of 50-100 mg intramuscularly or intravenously every 3-4 hours. The administration of morphine is not indicated, since it increases spasm of the sphincter of Oddi.

Antispasmodics and anticholinergics for symptomatic treatment.

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Surgical treatment of acute cholecystitis

Surgical treatment of acute cholecystitis is the most effective method of treating strictly cholecystitis. Until now, there is no consensus on the timing of cholecystectomy in acute cholecystitis. Traditionally, delayed (after 6-8 weeks) surgical treatment is considered after conservative therapy with mandatory prescription of antibiotics to relieve acute inflammation. However, data have been obtained showing that early (within a few days from the onset of the disease) laparoscopic cholecystectomy is accompanied by the same frequency of complications, but allows to significantly reduce the treatment time.

First of all, the possibility of early cholecystectomy should be discussed in all patients with acute cholecystitis in the first 24-48 hours after diagnosis. The endoscopic method of performing the operation is preferable (safer, cheaper, short hospitalization period). However, when preparing the patient for surgery, it should be borne in mind that due to various intraoperative circumstances, a need for laparotomy may arise.

In elderly and senile patients with leukocytosis against the background of acute cholecystitis, early cholecystectomy is also desirable due to the increased risk of complications from the gallbladder.

If cholecystectomy is not possible (for example, due to the patient's severe condition), it is necessary to discuss the possibility of performing cholecystostomy (percutaneous under ultrasound or CT control or through surgical access) as a temporary measure or an independent method of treatment.

Cholecystostomy ensures the drainage of bile, which helps to reduce or even eliminate inflammatory phenomena.

Percutaneous cholecystostomy is a safe and effective alternative to traditional surgery in a severe patient condition. It is especially indicated for elderly patients with complications of acute cholecystitis. The surgery is performed under ultrasound or fluoroscopy control after contrasting the gallbladder through a thin needle. The inserted catheter can be used for a single evacuation of the gallbladder contents (bile or pus) or for its long-term drainage. Bile or pus is sent for microbiological testing and intensive antibiotic therapy is continued. Usually, there is a rapid reverse development of symptoms, which allows the patient to be better prepared for a planned surgery. In an inoperable patient, the catheter can be removed after recovery, which is often complete against the background of conservative therapy.

It is necessary to take into account that with positive dynamics of a severe underlying disease, acute acalculous cholecystitis can be relieved on its own.

Further management of the patient

After cholecystectomy, the patient is observed by a surgeon, and subsequently by a gastroenterologist.

Patient education

The patient must be provided with full information about his disease and treatment tactics, information about the possible risk of developing life-threatening complications, and a justification for the need and scope of surgical intervention. Information about the risk of the surgical intervention itself must be given to the patient before he signs the informed consent form for the operation.