MEDICAL MANAGEMENT OF

CHOLECYSTITIS

NARCISO A. CAÑIBAN
CHOLECYSTITIS:

1. Initial treatment includes bowel rest: NPO

2. Intravenous hydration

3. Pharmacotherapy

> antiemetics
> anticholinergics
> analgesics
> antibiotics
DIET
Patients admitted for cholecystitis
should receive nothing by mouth
(NPO) and the insertion of
nasogastric tube for evacuation of
gastric contents (to eliminate
unnecessary stimulation to the
biliary system and to reduce
infectious exposure). However, in
uncomplicated cholecystitis, a
liquid or low-fat diet may be
appropriate until the time of
surgery.
IV therapy

Administer intravenous
(IV) fluids to correct any
dehydration and continue
as maintenance therapy.
Pharmacotherapy:

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.

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.
ANALGESICS

Pain is a prominent feature of cholecystitis. Several studies now have

shown that early pain control in patients with abdominal pain does not
hinder the diagnosis. Therefore, administer pain control early, without
waiting for the diagnosis or surgical consult. 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.

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.

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.
ANTIBIOTICS

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  white cells per cubic millimeter; temp
>38.5°C) and radiographic findings (eg, air in the gallbladder or gallbladder
wall).

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:

non–life-threatening cases:

Unasyn (Ampicillin and Sulbactam), Zosyn (Piperacillin and Tazobactam)

life-threatening cases:

Primaxin (Imipenem and Cilastatin)or meropenem. Alternatives include

metronidazole plus a third-generation cephalosporin or Cipro or Aztreonam.
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.
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. In a randomized trial of the use
of cefamandole in patients with acute
cholecystitis who underwent open
cholecystectomy, a short course (three
doses) was as effective as a 7-day course.
The first dose of an antibiotic should be
given within 1 hour before
cholecystectomy. It is advisable to culture
the gallbladder bile at the time of surgery to
guide the selection of antibiotics in the
event that postoperative septic
complications should arise.
THANK YOU