Acute cholecystitis: treatment

Indications for hospitalization

All patients with acute cholecystitis must be admitted to the surgical department.

Indications for specialist consultation

Acute cholecystitis is always an indication for a surgeon's advice. When an acute cholecystitis occurs against a background of severe pathology, the patient is observed by specialists of the appropriate profile.

Objectives of treatment of acute cholecystitis

• Preventing the development of complications and legal outcomes, for which the first priority is to timely resolve the issue of surgical treatment of acute cholecystitis.
• Reduction of the severity of the inflammatory process - antibacterial therapy, anti-inflammatory drugs.
• Symptomatic treatment: anesthesia, restoration of water-electrolyte balance.

Non-drug treatment of acute cholecystitis

Mode

Bed.

Diet

The necessary component of conservative therapy for acute cholecystitis is hunger.

Drug therapy for acute cholecystitis

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

[1], [2], [3], [4], [5], [6], [7], [8]

Antibiotics for acute cholecystitis

The feasibility of antibiotic therapy in all cases of acute cholecystitis, although still in doubt, is recognized by most 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 contents of the gallbladder gives rise to microflora in 30% of patients, after 72 hours - in 80%.

Escherichia coli is most often sown . Streptococcus faecalis and Klebsiella spp. or a combination thereof. Anaerobes can be found, for example Bacteroides spp. and Clostridia spp., which usually coexist with aerobes.

The choice of the drug depends on the type of pathogen detected during the sowing of bile, its sensitivity to antibiotics, and also on the ability of the antibacterial drug to penetrate and accumulate in the bile. The duration of treatment with antibiotics is 7-10 days. Preferably iv administration of drugs. Assign the following drugs: amoxicillin + clavulanate, cefoperazone, cefotaxime, neftriaxone, cefuroxime. Cephalosporins II and III generations, if necessary, combine with metronidazole.

Alternative variant: ampicillin 2 g IV every 6 h + gentamycin iv / metronidazole 500 mg IV every 6 hours (the most effective combination with a wide spectrum of antimicrobial action). It is also possible to use ciprofloxacin (including in combination with metronidazole).

[9], [10], [11]

Anesthesia and anti-inflammatory therapy

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

Meperidine (narcotic analgesic) in a dose of 50-100 mg IM or IV every 3-4 hours. Morphine is not indicated, since it increases spasm of the sphincter of Oddi.

Spasmolytics and anticholinergics for symptomatic treatment.

[12], [13], [14], [15], [16], [17]

Surgical treatment of acute cholecystitis

Surgical treatment of acute cholecystitis is the most effective method of treatment of strictly cholecystitis. Until now, there is no consensus on the timing of cholecystectomy in acute cholecystitis. Traditional consider postponed (after 6-8 weeks) surgical treatment after conservative therapy with mandatory prescription of antibiotics for relief of acute inflammation. However, data have been obtained that early (within a few days after the onset of the disease) laparoscopic cholecystectomy is accompanied by the same frequency of complications, but it allows to significantly shorten the duration of treatment.

First of all it is necessary to discuss the possibility of early cholecystectomy in all patients with acute cholecystitis in the first 24-48 hours after diagnosis. Preferably, the endoscopic method of surgery (safer, cheaper, short duration of hospitalization, nevertheless, when preparing a patient for surgery, it should be borne in mind that due to various intraoperative circumstances, there may be a need for laparotomy.

Patients of elderly and senile age with leukocytosis on the background of acute cholecystitis also prefer early cholecystectomy due to an increased risk of complications from the gallbladder.

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

Cholecystostomy provides the removal of bile, which contributes to the subsidence or even the disappearance of inflammatory phenomena.

Percutaneous cholecystostomy is a safe and effective alternative to traditional surgery in case of a serious condition of the patient. It is especially indicated for elderly patients with complications of acute cholecystitis. The operation is performed under the supervision of ultrasound or fluoroscopy after contrasting the gallbladder through a thin needle. The inserted catheter can be used for a single evacuation of the contents of the gallbladder (bile or pus) or its long drainage. Bile or pus sent to a microbiological study and continue intensive therapy with antibiotics. Usually there comes a rapid reverse development of symptoms, which allows you to better prepare the patient for the planned operation. In an inoperable patient, the catheter can be removed by recovery, which is often complete with conservative therapy.

It should be borne in mind that with a positive dynamic of a severe underlying disease, acute acalculous cholecystitis can be self-contained.

Further management of the patient

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

Patient education

The patient must provide full information about his illness and treatment tactics, information about the possible risk of complications, life-threatening, justification of the need and scope of surgical intervention. Information about the risk of the most surgical intervention must be given to the patient before signing the form of informed consent to the operation.