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AUTHOR INFORMATION
| Section 1 of 11   |
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| Author: Alan A Bloom, MD, Associate Clinical Professor, Department of Medicine, Bronx Lebanon Hospital, Albert Einstein College of Medicine Coauthor(s): Prospere Remy, MD, Assistant Professor of Medicine, Albert Einstein College of Medicine, Division Chief and Fellowship Director, Departments of Gastroenterology and Hepatology Services, Bronx-Lebanon Hospital Center |
| Alan A Bloom, MD, is a member of the following medical societies:
American College of Physicians,
American Gastroenterological Association,
American Medical Association,
American Society for Gastrointestinal Endoscopy,
New York Academy of Medicine, and
New York Academy of Sciences |
| Editor(s): Burt Cagir, MD, FACS, Assistant Professor of Surgery, State University of New York, Upstate Medical Center; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine;
BS Anand, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor University College of Medicine;
Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine;
and Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania |
Disclosure
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INTRODUCTION
| Section 2 of 11   |
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Background: Emphysematous cholecystitis is an acute infection of the gallbladder wall caused by gas-forming organisms. Described by Stoltz in 1901, it was thought to be a rare disorder. However, as a result of improved imaging techniques, it is now being described with increasing frequency. Pathophysiology: Four pathogenetic factors are proposed in the development of emphysematous cholecystitis.
Vascular compromise of the gallbladder
In most cases, the cystic artery is the sole arterial supply of the gallbladder. Occlusion or stenosis results in impaired viability of the gallbladder. Arteriosclerosis is the usual causative abnormality, although the condition has been described after an embolic event. The evidence that vascular insufficiency is a root cause of emphysematous cholecystitis is circumstantial, ie, association with diabetes mellitus, greater incidence in males, high frequency of gangrene, and occurrence in older patients. However, exceptions exist for each of these.
Gallstones
Gallstones are observed in 28-80% of patients with emphysematous cholecystitis. Impaction of stones in the cystic duct leads to localized edema of the wall, which contributes to the vascular compromise of the gallbladder. Nevertheless, emphysematous cholecystitis in the presence of acalculous cholecystitis is well established. Indeed, the proportion of patients with acalculous cholecystitis in association with emphysematous cholecystitis exceeds that of patients with ordinary acute cholecystitis. These observations raise doubt about the role of gallstones in the pathogenesis of emphysematous cholecystitis.
Impaired immune protection
Diabetes mellitus is detected in 38-55% patients with emphysematous cholecystitis, and the mean age of patients is 59 years. Both the metabolic abnormality and older age probably contribute to the increased risk of infection.
Infection with gas-forming organisms
Microorganisms commonly isolated are clostridial species, Escherichia coli, and Klebsiella species. Less frequently, enterococci and anaerobic streptococci are among the other organisms detected. While the intramural gas observed in patients with emphysematous cholecystitis seems to result from gas-forming bacteria, whether these bacteria represent the primary cause of the disorder or are secondary invaders remains unclear. Frequency:
- In the US: Emphysematous cholecystitis occurs infrequently. Reports in the surgical literature indicate that emphysematous cholecystitis develops in approximately 1% of all cases of acute cholecystitis. An estimated 500,000 cholecystectomies are performed per year in the United States. Assuming all with emphysematous cholecystitis come to surgery, this would indicate that 5000 cholecystectomies are performed per year for emphysematous cholecystitis. While the number of patients who are treated successfully without surgery is certainly small, the number of patients who die without surgery is unknown.
Mortality/Morbidity: Overall mortality rates vary from 15-25%. These rates are 5 times the operative mortality rates for nonemphysematous cholecystitis. In addition to the septic character of the disease, comorbidities attendant to advanced age and diabetes mellitus also add to the risk of mortality.
Race: No racial predilection has been described.
Sex: Unlike other biliary tract disorders, emphysematous cholecystitis occurs more frequently in men; men comprise 65-70% of all patients with emphysematous cholecystitis.
Age: The disease occurs more commonly in older patients. In one study, the mean age of 20 patients was 59 years, and, in another study, 59% of patients were aged 60 years or older.
History: The typical patient is a male older than 60 years, often with type II diabetes mellitus. Otherwise, the clinical scenario does not differ significantly from that observed in acute cholecystitis. - Pain is localized to the right upper quadrant and often radiates to the back. It is unrelated to position or physical activity.
- An antecedent history of self-limited episodes of pain may be present. However, the clinician must be aware that elderly patients may develop acute intra-abdominal disorders with little or no localizing symptoms or signs.
Physical: - Physical examination usually reveals an elderly patient with fever and tachycardia.
- Abdominal examination shows tenderness in the right upper quadrant.
- An enlarged tense gallbladder may be noted, best demonstrated by light palpation.
- Bowel sounds are diminished or absent, especially if peritonitis has supervened.
- Jaundice is unusual unless a concomitant common duct obstruction and/or intrahepatic disease is present.
- Transient relief of right upper quadrant pain followed by the appearance of peritoneal signs is the hallmark of perforation.
Causes: See Pathophysiology.
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DIFFERENTIALS
| Section 4 of 11 |
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Cholecystitis
Other Problems to be Considered:
Two levels of differential diagnosis should be considered: clinical and radiologic.
The clinical differential diagnosis is that of acute cholecystitis (nonemphysematous), both calculous and acalculous.
The radiologic differential is that of finding gas in the biliary tree, which may be due to a biliary-enteric fistula (spontaneous or surgical); may occur after an endoscopic retrograde cholangiopancreatography, especially following a sphincterotomy; or may be due to cholangitis caused by gas-forming organisms. |
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Patient Education
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Lab Studies:
- Patients have leukocytosis that is, at times, strikingly high.
- Liver tests results are usually normal or slightly elevated (aspartate aminotransferase [AST], alanine aminotransferase [ALT]), reflecting the patient's febrile state. Very abnormal liver test results, especially alkaline phosphatase, bilirubin, or gamma-glutamyl transpeptidase (GGTP), suggest a common duct obstruction or intrahepatic disease.
- Urinalysis, chest radiograph, and electrocardiogram add little to the diagnosis but should be obtained as part of the preoperative assessment of the patient.
Imaging Studies:
- Imaging studies are the key diagnostic maneuvers.
- Abdominal radiographs show the classic picture of a gallbladder wall containing gas. The gallbladder is often fluid-filled, and gas that has leaked into its lumen collects in the least dependent portion. The absence of a gas-filled gallbladder wall on an abdominal radiograph does not exclude a diagnosis of emphysematous cholecystitis.
- Inflammation and gas formation may extend to the pericholecystic tissues and extrahepatic ducts. This picture has been regarded as the sine qua non of emphysematous cholecystitis; that such a radiologic image is very specific is in little doubt.
- With the advent of other imaging techniques, especially CT scan, the importance of plain radiographs of the abdomen has declined; further, the presence of abnormal findings on a plain film of the abdomen may indicate advanced disease.
- Changes noted on CT scan and ultrasound of the abdomen can be observed before the classic abnormalities are visible on plain abdominal radiograph.
- The classic picture observed on abdominal radiographs is believed to represent a late phase in the evolution of emphysematous cholecystitis and may presage a poorer outcome.
- Obfuscation of the gallbladder by high-level echoes occurs when gas accumulates in the wall and lumen of the gallbladder and renders differentiation from intestinal gas difficult. This finding is not diagnostic of emphysematous cholecystitis. The alert physician questions the paradoxical absence (ie, sonographic nonvisualization) of a gallbladder in the clinical setting of a patient who likely has gallbladder disease.
- Curvilinear gaseous artifacts in the gallbladder, the "ring-down effect" or "comet tail," are diagnostic of emphysematous cholecystitis, but the frequency with which these are observed is not clear.
- As the gas leaks out from the wall of the gallbladder into the bile, a picture described as "effervescent bile" can be observed.
- Computerized tomography scan of the abdomen
- CT scan demonstrates emphysematous changes in the gallbladder wall that are diagnostic of this condition. CT scan may also demonstrate extension into the pericholecystic tissues and the hepatic ducts. Gas in the peritoneum indicates perforation.
- CT scan is emerging as the most sensitive and specific diagnostic study. It should be performed first if the clinical picture warrants. It should certainly be performed if ultrasound and abdominal radiograph findings are not diagnostic.
- Magnetic resonance imaging of the abdomen
- Experience remains very limited with MRI. In one report, a gas-fluid level was shown by a signal void in the nondependent portion of the gallbladder contrasted against an intermediate signal intensity in the dependent portion. Gas within the wall was demonstrated by a rim of low signal intensity. Extraluminal gas, suggesting perforation, may cause small magnetic field inhomogeneous collections referred to as "blooming" artifacts.
- These findings are preliminary. No data as to its sensitivity or reliability are available. Further experience should resolve these questions.
- MRI will likely prove to be as diagnostic as CT scan and would be of particular value in pregnant women.
Histologic Findings: Following the invasion of the wall by gas-forming bacteria, the different layers of the gallbladder wall become separated, leading to the characteristic tissue crepitus. Histologically, colonies of bacteria can be observed forming intramural abscesses. Gallbladder contents are often purulent. Even with prompt intervention, necrosis and gangrene are observed in 75% of gallbladders at surgery, and nearly 20% of the gallbladders perforate.Staging: Staging is crude and image-based: Diagnostic visualization on plain radiographs of the abdomen is thought to represent late-stage disease. CT imaging differentiates pre-perforation disease from post-perforation disease.
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TREATMENT
| Section 6 of 11 |
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Medical Care: Although sporadic cases of presumed emphysematous cholecystitis treated only with antibiotics and supportive measures are described, it should be emphasized that definitive management requires surgical intervention. - Intravenous antibiotics of choice are those that have beta-lactamase inhibitor activity or combinations that provide coverage for anaerobic and gram-negative organisms.
- Fluid replacement and correction of electrolyte deficits should be initiated to prepare the patient for surgery. The authors emphasize that these temporary and preparatory maneuvers are not intended to reverse the basic disease process.
Surgical Care: Management of emphysematous cholecystitis is surgical. Antibiotics and fluid replacement are started immediately to stabilize the patient, but because of the risk of perforation and its impact on survival, clinicians tend to proceed to surgery with deliberate speed. Overall, surgical mortality rates vary from 15-25%. - Recently, interventional radiologic techniques have been described that allow drainage and decompression followed by interval excision of the gallbladder. These techniques have been used in patients with complications such as perforation and in those with high surgical risk.
- Despite the small number of instances where these techniques have been used, improved surgical survival has been noted. However, the following important issues remain unresolved:
- Many patients have negative findings on abdominal radiograph and are diagnosed using ultrasound and CT scan. This means that the disease process was at an early stage of its evolution, and it may have been amenable to delayed surgical intervention and may have responded to concomitant antibiotic therapy.
- The case descriptions do not clarify the appropriate interval between interventional drainage and surgical excision of the gallbladder.
- At the very least, current experience suggests that interventional radiological drainage can be performed without increasing the overall mortality rate and appears to be a reasonable temporizing option in a seriously ill patient.
- Hopefully, interventional radiology will be demonstrated to lower surgical mortality rates, but it does not yet obviate the need for surgical removal of the gallbladder. Further experience is required to determine the role of percutaneous transhepatic gallbladder drainage. The final management algorithm for emphysematous cholecystitis has yet to been written.
- Experience with laparoscopic cholecystectomy continues to increase. While laparoscopic cholecystectomy is clearly feasible, the small number of cases does not allow valid comparisons for mortality and complications. A preoperative diagnosis of perforation would likely preclude a laparoscopic approach, thereby requiring a preoperative CT or MRI of the abdomen.
Consultations: - Consultation with surgical and internal medicine specialists is indicated in all cases.
- If available, the services of an interventional radiologist is indicated when percutaneous gallbladder drainage is considered an option. This would be especially true in a patient who is seriously ill and/or has multiple comorbidities.
- Consultation with specialists in infectious diseases is indicated for optimal selection of antibiotics.
- Consultation with other medical subspecialists depends on the array of comorbid conditions present.
Diet: - The patient should not be given anything by mouth until a decision has been made regarding surgery.
- Postoperative feedings are dictated by surgical considerations.
- Upon discharge, dietary recommendations reflect the presence of active comorbid diseases.
- The episode of emphysematous cholecystitis itself should not impose any dietary requirements.
Activity: - Early postoperative activity is dictated by surgical considerations.
- Upon discharge after the operation, the patients should experience no limitation of activity that was not present before the episode.
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MEDICATION
| Section 7 of 11 |
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Medications reflect the need to control infection and manage comorbidities. The 3 most common organisms isolated in patients with emphysematous cholecystitis are E coli, Klebsiella species, and clostridial species. Antibiotic regimens are suggested with the following caveats: (1) antibiotics are not definitive therapy for this condition and (2) antibiotic regimens should be evaluated in light of changing bacterial sensitivities, changing antibiotic options, and changing patient characteristics.
Drug Category: Antibiotics -- Therapy must be comprehensive and cover all likely pathogens in the context of the clinical setting. In the absence of sensitivity data, antibiotic selection is based on empirical considerations including the most likely organisms present and contraindications reflecting the patient's comorbidities and history of sensitivity.
The use of a single effective broad-spectrum fixed antibiotic combination offers simplicity of administration, relative safety, and limited drug interactions.
The use of multiple antibiotics increases the range of therapeutic options in the event of hypersensitivity to one or more single agents or in the event of a loss of sensitivity of one or more organisms to the range of a single agent.
Suggested drug combinations are gentamicin plus metronidazole and levofloxacin plus ceftriaxone.
Cultures obtained as a result of intervention should be used to focus the selection of antibiotics. Drug Name
| Imipenem and cilastin (Primaxin) -- For treatment of infections caused by multiple organisms in which other agents do not have broad-spectrum coverage or are contraindicated because of potential for toxicity.
Because emphysematous cholecystitis is characterized by necrosis, perforation, and a high mortality rate, higher doses are advisable.| Adult Dose | Base initial dose on the severity of infection and administer in equally divided doses
250-500 mg IV q6h; not to exceed 3-4 g/d
500-750 mg IM or intra-abdominally q12h| Pediatric Dose | <12 years: Not established
>3 months: 15-25 mg/kg/dose IV q6h suggested
Fully susceptible organisms: Not to exceed 2 g/d
Infections with moderately susceptible organisms: Not to exceed 4 g/d| Contraindications | Documented hypersensitivity |
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| Interactions | Coadministration with cyclosporine may increase adverse CNS effects of both agents; coadministration with ganciclovir may result in generalized seizures; effects may be prolonged by probenecid |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Adjust dose in renal insufficiency; caution in children <12 y; monitor for development of pseudomembranous colitis |
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Drug Name
| Piperacillin and tazobactam (Zosyn) -- Antipseudomonal penicillin plus beta-lactamase inhibitor. It inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication. |
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| Adult Dose | 3.375 g IV q6h |
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| Pediatric Dose | 75 mg/kg IV q6h |
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| Contraindications | Documented hypersensitivity |
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| Interactions | May inactivate aminoglycosides; probenecid may increase penicillin levels; neuromuscular blockade if used with vecuronium; may produce false-positive results for glucose if Clinitest tab is used to test urine |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy (this may be complicated by elevations in the transferases associated with emphysematous cholecystitis); use caution in patients diagnosed with hepatic disorders; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions; monitor for appearance of pseudomembranous enterocolitis |
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Drug Name
| Ticarcillin and clavulanate (Timentin) -- Inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive, gram-negative, and anaerobic organisms. |
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| Adult Dose | 3.1 g IV q4-6h |
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| Pediatric Dose | 75 mg/kg IV q6h |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; the effects are synergistic when administered concurrently with aminoglycosides; probenecid may increase penicillin levels |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during treatment; exercise caution in patients diagnosed with hepatic insufficiency; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions |
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Drug Name
| Ampicillin and sulbactam (Unasyn) -- Drug combination of beta-lactamase inhibitor with ampicillin. Covers epidermal organisms, enteric flora, and anaerobic organisms. Not ideal for nosocomial pathogens. |
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| Adult Dose | 1.5 g (1 g ampicillin plus 0.5 g sulbactam) to 3 g (2 g ampicillin plus 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin |
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| Pediatric Dose | <3 months: Not established
3 months to 12 years: 100-200 mg/kg/d ampicillin (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction |
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Drug Name
| Gentamicin (Garamycin) -- Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobic organisms.
Not the drug of choice. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.
Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be administered IV/IM.| Adult Dose | Serious infections and normal renal function: 3 mg/kg/d IV q8h
Loading dose and maintenance dose: 1-2.5 mg/kg IV and 1-1.5 mg/kg IV, respectively, q8h
Extended dosing regimen for life-threatening infections: 5 mg/kg/d IV/IM q6-8h
Follow each regimen by at least a trough level drawn after the third or fourth dose (0.5 h before dosing); may draw a peak level 0.5 h after 30-min infusion| Pediatric Dose | <5 years: 2.5 mg/kg per dose IV/IM q8h
>5 years: 1.5-2.5 mg/kg per dose IV/IM q8h or 6-7.5 mg/kg/d divided q8h; not to exceed 300 mg/d; monitor as in adults| Contraindications | Documented hypersensitivity; non–dialysis-dependent renal insufficiency |
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| Interactions | Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (requires regular monitoring) |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment |
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Drug Name
| Metronidazole (Flagyl) -- Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis). |
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| Adult Dose | Loading dose: 15 mg/kg (1 g for 70-kg adult) IV over 1 h
Maintenance dose: 6 h following loading dose, 7.5 mg/kg (500 mg for 70-kg adult) IV infused over 1 h q6-8h; not to exceed 4 g/d| Pediatric Dose | Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Cimetidine may increase toxicity of metronidazole; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy; caution in women who are breastfeeding or in first trimester of pregnancy |
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Drug Name
| Levofloxacin (Levaquin) -- For pseudomonal infections and infections caused by multi-drug–resistant gram-negative organisms. |
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| Adult Dose | 500 mg PO qd for 7-14 d |
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| Pediatric Dose | <18 years: Not recommended
>18 years: Administer as in adults| Contraindications | Documented hypersensitivity |
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| Interactions | Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, NSAIDs, oral hypoglycemics, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT) |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy |
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Drug Name
| Ceftriaxone (Rocephin) -- Third-generation cephalosporin with broad-spectrum gram-negative activity. Lower efficacy against gram-positive organisms. Higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins. |
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| Adult Dose | Uncomplicated infections: 250 mg IM once; not to exceed 4 g
Severe infections: 1-2 g IV qd or divided bid; not to exceed 4 g/d| Pediatric Dose | >7 days: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in renal impairment; caution in women who are breastfeeding and in those allergic to penicillin |
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Drug Name
| Ertapenem (Invanz) -- Bactericidal activity results from inhibition of cell wall synthesis and is mediated through ertapenem binding to penicillin-binding proteins. Stable against hydrolysis by a variety of beta-lactamases including penicillinases, cephalosporinases, and extended-spectrum beta-lactamases. Hydrolyzed by metallo-beta-lactamases. |
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| Adult Dose | 1 g qd for 14 d if IV and 7 d if IM; infuse over 30 min if IV |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity to drug or amide-type anesthetics |
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| Interactions | Probenecid may reduce renal clearance of ertapenem and increase half-life, but benefit is minimum and does not justify coadministration |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Pseudomembranous colitis may occur; seizures and CNS adverse reactions may occur; when using with lidocaine to administer intramuscularly, avoid inadvertent injection into blood vessel |
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Drug Name
| Cefepime (Suprax) -- Fourth-generation cephalosporin. Gram-negative coverage comparable to ceftazidime but has better gram-positive coverage (comparable to ceftriaxone). Cefepime is a zwitter ion; rapidly penetrates gram-negative cells. Best beta-lactam for IM administration. |
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| Adult Dose | 1-2 g IV q12h for 5-10 d; pseudomonal infections require higher doses |
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| Pediatric Dose | 50 mg/kg IV q8h; not to exceed 2g |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid may increase effects of cefepime; aminoglycosides increase the nephrotoxic potential of cefepime |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Dosage adjustments (adult adjustments)
CrCl (mL/min) 80-50: 0.5-2 g q12-24h
CrCl 50-10: 0.5-2 g/d
CrCl <10: 0.25-0.5 g/d
HD: As for CrCl <10, with an extra 0.25 g after HD
During peritoneal dialysis: 1-2 g q48h
High doses may cause CNS toxicity; prolonged use of cefepime may predispose patients to superinfection |
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FOLLOW-UP
| Section 8 of 11 |
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Further Inpatient Care:
- Patients should be observed for the development of pseudomembranous enterocolitis manifested by diarrhea. This diagnosis is established by demonstrating C difficile toxin in the stool. Treatment is usually started with metronidazole and switched to vancomycin if metronidazole fails to elicit a response.
- Patients should be observed for the development of early postoperative complications such as leak from the cystic duct stump and retained common duct stone.
Further Outpatient Care:
- Patients should be observed for the development of common duct stricture and/or postcholecystectomy diarrhea.
In/Out Patient Meds:
- Antibiotics should be continued until optimal control of infections is obtained.
Complications:
- Early and late complications are those associated with the interventional procedure.
Prognosis:
- The mortality rate approaches 15%. In a recent report of 18 patients, there were no deaths in the immediate postoperative period; 13 of the 18 patients had laparoscopic cholecystectomy.
Patient Education:
- Patients should be educated to watch for features of bile duct obstruction, such as changes in the color of the skin, eyes, urine, and stool, which may indicate a retained common duct stone or stricture.
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MISCELLANEOUS
| Section 9 of 11 |
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Medical/Legal Pitfalls:
- Although most patients have the typical clinical presentation as described, the clinician must be aware of the following:
- Older patients may not present with significant abdominal pain or fever, even in the presence of frank peritonitis.
- A plain film of the abdomen may not be diagnostic.
- The gallbladder may not be readily observed on ultrasound examination. Indeed, the apparent absence of a visualized gallbladder on ultrasound in a patient with biliary tract features should prompt the clinician to proceed to abdominal CT.
- Ultimately, CT scan seems to be the most reliable diagnostic test.
Special Concerns:
- Although emphysematous cholecystitis occurs more frequently in older patients, it has been described in women of childbearing age.
- In view of the limitations on the use of radiologic studies in pregnancy and the truncated usefulness of abdominal ultrasound, the diagnosis of emphysematous cholecystitis in pregnant patients is especially challenging.
- Open-bed magnetic resonance imaging (MRI) may prove to be a useful option, although its use has not been widely reported.
- This is of particular importance because surgical treatment for emphysematous cholecystitis cannot be deferred, as is the case for nonemphysematous acute cholecystitis.
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PICTURES
| Section 10 of 11 |
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| Caption: Picture 1. Emphysematous cholecystitis. A 47-year-old man with diabetes who experienced abdominal pain. Computerized tomography scan shows gas within the wall of the gallbladder (horizontal arrow) as well as within the lumen of the gallbladder (vertical arrow). Radiograph courtesy of Helen Morehouse, MD.
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Picture Type: CT |
| Caption: Picture 2. Emphysematous cholecystitis. A 61-year-old nondiabetic man with right upper quadrant abdominal pain, fever, and leukocytosis. Film shows the gallbladder with multiple stones. The wall of fundus is delineated by intramural gas. Extramural gas also appears to be present in the soft tissues over the superior aspect of the gallbladder.
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Picture Type: X-RAY |
| Caption: Picture 3. Emphysematous cholecystitis. A 78-year-old man with diabetes with minimal abdominal distress. The film shows an enlarged gallbladder with multiple stones. The wall of the gallbladder is outlined by intramural gas.
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Picture Type: X-RAY |
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BIBLIOGRAPHY
| Section 11 of 11 |
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Andreu J, Perez C, Caceres J, et al: Computed tomography as the method of choice in the diagnosis of emphysematous cholecystitis. Gastrointest Radiol 1987; 12(4): 315-8[Medline].
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