From the Guidelines
The treatment for emphysematous cholecystitis requires urgent surgical intervention with cholecystectomy, along with broad-spectrum antibiotics, as it is a medical emergency with high mortality rates. The most recent and highest quality study, published in 2020 1, recommends laparoscopic cholecystectomy as the preferred treatment for patients who are fit to undergo surgery. However, for emphysematous cholecystitis, the condition is more severe and requires immediate attention. Patients should be started immediately on antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of a third-generation cephalosporin like ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours, as these target both aerobic and anaerobic bacteria, particularly gas-forming organisms like Clostridium perfringens and E. coli that cause this condition.
Key Considerations
- Fluid resuscitation and correction of electrolyte imbalances are essential prior to surgery.
- While laparoscopic cholecystectomy is preferred, open cholecystectomy may be necessary in severely ill patients or those with extensive inflammation.
- For patients who cannot tolerate immediate surgery, percutaneous cholecystostomy (gallbladder drainage) can serve as a temporary measure until definitive surgery is possible.
Antibiotic Selection
The choice of antibiotics should be based on the suspected or confirmed causative organisms, and should provide coverage against Enterobacteriaceae, as recommended by the 2003 guidelines for the selection of anti-infective agents for complicated intra-abdominal infections 1. However, the most recent study 1 does not provide specific guidance on antibiotic selection for emphysematous cholecystitis.
Surgical Intervention
The 2020 study 1 provides strong evidence for the recommendation of early laparoscopic cholecystectomy (ELC) for acute cholecystitis, with a significant reduction in hospital stay and return to work compared to delayed laparoscopic cholecystectomy (DLC) or intermediate laparoscopic cholecystectomy (ILC). However, for emphysematous cholecystitis, the condition is more severe and requires immediate attention, and the recommendation for ELC should be considered in the context of the patient's overall condition and the availability of surgical expertise.
From the Research
Treatment for Emphysematous Cholecystitis
The treatment for emphysematous cholecystitis typically involves a combination of antibiotic therapy and surgical intervention.
- Empirical antibiotic therapy with broad-spectrum antibiotics, such as piperacillin-tazobactam, is often initiated as soon as possible 2.
- Surgical intervention, including cholecystectomy and surgical debridement, is usually necessary to remove the infected gallbladder and prevent further complications 2, 3.
- In some cases, percutaneous cholecystostomy may be performed as an alternative to immediate surgery, especially in patients who are severely ill or at high risk for surgery 4, 5.
- The choice of antibiotic therapy should be guided by the severity of the infection, the patient's medical history, and local bacterial susceptibility patterns 6.
- It is essential to obtain microbial cultures of the bile to identify the causative organisms and adjust the antibiotic therapy accordingly 6.