What is the normal treatment course for an occluded infected gallbladder?

Treatment of Occluded Infected Gallbladder

The standard treatment for an occluded infected gallbladder is early laparoscopic cholecystectomy within 7-10 days of symptom onset, combined with appropriate antibiotic therapy. 1

Diagnosis

• First-line imaging: Ultrasonography (sensitivity ~81%, specificity ~83%)
  • Key findings: gallstones, gallbladder wall thickening, pericholecystic fluid, distended gallbladder, positive sonographic Murphy's sign 1
• Alternative imaging: CT with IV contrast if ultrasound is inconclusive 1
• Clinical signs: Right upper quadrant pain, Murphy's sign, fever, abdominal tenderness 2

Treatment Algorithm

1. Surgical Management

• Primary treatment: Early laparoscopic cholecystectomy within 7-10 days of symptom onset 2, 1

  • Preferred approach due to lower mortality and better outcomes, especially in elderly patients 1
  • Open cholecystectomy as an alternative if laparoscopic approach not feasible 2

• Alternative for high-risk patients: Percutaneous cholecystostomy

  • Consider for patients with multiple comorbidities unfit for surgery who don't improve after antibiotic therapy 2, 1
  • Note: Cholecystostomy is inferior to cholecystectomy in terms of major complications for critically ill patients 2

2. Antibiotic Therapy

For non-critically ill, immunocompetent patients:

• First-line: Amoxicillin/Clavulanate 2g/0.2g q8h 2
• If beta-lactam allergy:
  • Eravacycline 1 mg/kg q12h OR
  • Tigecycline 100 mg loading dose, then 50 mg q12h 2
• Duration: 4 days if source control is adequate 2

For critically ill or immunocompromised patients:

• First-line: Piperacillin/tazobactam 6g/0.75g loading dose then 4g/0.5g q6h or 16g/2g by continuous infusion 2, 1
• Duration: Up to 7 days based on clinical condition and inflammatory markers 2

Important Considerations

• Timing is critical: Delaying surgery beyond 72 hours increases complication rates 1
• Antibiotic duration: Patients with ongoing signs of infection beyond 7 days warrant further diagnostic investigation 2
• Monitoring: Daily assessment of clinical response and renal function, especially in elderly patients 1
• Fluid management: Goal-directed fluid therapy for resuscitation 1

Potential Complications

• Bile duct injuries (serious complication of laparoscopic cholecystectomy) 1
• Gangrenous cholecystitis, emphysematous cholecystitis, gallbladder perforation, and hemorrhagic cholecystitis 1
• Higher mortality rates in acalculous cholecystitis (45.2%) compared to calculous cholecystitis (21.2%) 1

Cautions

• Elderly patients may require antibiotic dose adjustments due to altered pharmacokinetics 1
• Patients with renal/hepatic dysfunction require careful monitoring and potential dose adjustments 1
• Unnecessary prolonged antibiotic therapy increases the risk of resistance 1
• Aminoglycosides should be used cautiously in elderly patients with biliary infections due to potential nephrotoxicity 3