Cholecystitis Empiric Therapy

Introduction:

Gallbladder is one of the most important parts of the digestive system. Diseases of the gallbladder, like gallstone formation, are very common. Around 10 to 15 percent of the adult population suffer from such complications. Cholecystitis is caused by the gallstone. It is one of the serious complications characterized by severe pain in the abdomen. Antibiotics, along with surgical interventions, are needed to treat such cases.

What Is Acute Cholecystitis?

One of the most common sources of complicated abdominal infection is acute calculous cholecystitis. Around 18.5 percent of cases of intra-abdominal infection are caused by this infection. It is the inflammation of the gallbladder caused by the blockage of the cystic duct.

1. Causative Factors:

Gallbladder acts as a storage site for the bile. It also helps in the concentration of the bile. Bile is formed in the liver and travels to the gallbladder through the bile duct. Bile is made up of bile salts, conjugated bilirubin, phospholipids, cholesterol, water, and electrolyte. The function of the bile is the emulsification of the fat and absorption of the lipid. Also, the elimination of waste products is facilitated by bile. Food intake, specifically spicy, leads to the secretion of the hormone cholecystokinin. This causes the contraction of the gallbladder. As a result, the stored, concentrated bile is passed through the cystic duct to the common bile duct to the duodenum.

Cholesterol stone, bile pigment stone, and bile salt stone are the three different types of gallbladder stone. Cholesterol stones are formed because of the impaired relationships among the bile components like cholesterol, phospholipids, and bile acids. This mechanism is also responsible for the formation of black bile stones. Enzymatic hydrolysis of the bile lipid due to the infections is responsible for the formation of brown pigment bile stone. Anaerobic bacteria are responsible for the supersaturation of the bile and deconjugation of bile salts. Along with this, gallbladder hypomotility, obesity, and genetic factors play crucial roles in the formation of gallstones. These stones are responsible for the blockage of the cystic bile duct. This blockage reduces the blood supply of that region and causes edema and inflammation. Gradually this leads to gangrenous necrosis of that area. The blockage of the cystic bile duct is known as acute calculous cholecystitis. Gradually this area is infected by the gas-forming microorganisms. This is known as acute acalculous cholecystitis.

2. Diagnosis:

The diagnosis of acute calculous cholecystitis is the most important factor. Tokyo guidelines are the most important factor for diagnosing and determining the treatment protocol for cholecystitis. The diagnosis is based on the following criteria:

• Presence of fever and shivering.

• Murphy's sign (pain in the right subcostal area during palpation) is positive in the subjects and pain, and tenderness can be noted in the right upper quadrant of the abdomen.

• The presence of an increased amount of leucocytes (more than 11000 per microliter of blood) and the level of C-reactive protein in the blood is elevated.

• The bilirubin level in the blood is elevated.

• Elevated levels of the liver enzymes like ALP (alkaline phosphatase), ALT (alanine transaminase), AST (aspartate aminotransferase), and gamma-glutamyl transferase (GGT) can be observed.

• Image analysis of the abdomen, like an ultrasound examination, will show the dilation of the bile duct and the presence of stone in the gallbladder.

Following these criteria, the severity of the disease is determined. The categorization for severity are:

• Grade I: In the grade I condition, the amount of inflammation is mild. There are no severe symptoms, and the amount of pain is mild.

• Grade II: The amount of inflammation is severe with the presence of conditions like a pericholecystic abscess (abscess of the gallbladder), hepatic abscess (liver abscess), and biliary peritonitis (a condition in which bile drains into the abdominal cavity). In this case, the symptoms like pain, tenderness, and fever persist for more than 72 hours. A palpable solid mass in the right upper quadrant and an increased amount of white blood cells in the blood can be seen.

• Grade III: In this condition, severe infection with the involvement of several organs can be seen. Respiratory discomfort, liver dysfunction, and cardiovascular dysfunctions can be seen.

What Are the Utilization of Empiric Therapy?

Empiric therapy is also known as anti-microbial therapy. Different microorganisms like Escherichia coli, Klebsiella, Enterococcus, Streptococcus species, and anaerobic bacteria can be found in this condition. According to some research, the gallbladder is rich in blood supply. As a result, antibiotic therapy can be used to reduce the amount of the microorganism. But, on the basis of the Tokyo guidelines, antibiotics can be given only in the following cases.

1. Antibiotic therapy can be useful in Grade I conditions, as infections and inflammation are mild in such cases.

2. Pre-operative antibiotic therapy in the cases of Grade II and Grade III cases. This type of antibiotic therapy reduces the chances of post-operative infection and wound infections. Such type of antibiotic therapy is mainly indicated in immunocompromised patients.

3. Intra-operative antibiotics reduce the chances of the spread of infection from contaminated bile.

4. In post-operative conditions, antibiotics can be useful in infection control. According to many researchers, continuation of antibiotics for more than 24 hours is not necessary as it does not beneficial in controlling infections.

What Are the Antibiotics Used in Acute Cholecystitis?

Different antibiotic regimes can be followed according to the severity of the conditions. These are:

1. In Grade I cases, oral Fluoroquinolones like Levofloxacin and Ciprofloxacin can be prescribed. Other than this, oral cephalosporins like Cefotiam, Cefcapene, and Cefazolin can also be given. Beta-lactamase inhibitors like Ampicillin or Sulbactam can be useful in such cases.

2. In Grade II and Grade III cases, wide-spectrum penicillin or beta-lactamase inhibitors like Piperacillin or Tazobactam and Ampicillin or Sulbactam can be used. Ciprofloxacin 400 milligrams three times a day is considered the second line of drugs. Such drugs are used in cases of moderate infection with no sign of organ involvement.

3. In severe cases of cholecystitis, third or fourth-generation cephalosporins like Cefoperazone, Ceftriaxone, Ceftazidime, Cefepime, and Cefozopran can be given. Along with this Metronidazole is also prescribed.

4. Ciprofloxacin, Levofloxacin, Pazufloxacin, and Metronidazole can be given for the second line of drugs.

Conclusion:

Gallstone is responsible for obstruction of the cystic duct. This causes gradual inflammation and necrosis of the duct and leads to cholecystitis. Severe pain, inflammation, and involvement of the vital organs can be seen in such cases. Empiric antibiotic therapy can be used in the treatment of mild cases. Also, it can be used as an adjunct in surgical intervention.