What are the non-antibiotic pre-operative management strategies for cholecystitis/cholangitis?

Non-Antibiotic Pre-Operative Management of Cholecystitis/Cholangitis

The primary non-antibiotic pre-operative management for cholecystitis and cholangitis focuses on biliary decompression through endoscopic or percutaneous drainage, along with appropriate fluid resuscitation, pain management, and supportive care. 1, 2

Acute Cholecystitis Management

Fluid Resuscitation

• Initial fluid resuscitation with normal saline (NS) or lactated Ringer's (LR) solution at 10 ml/kg/hour 2
• Goal-directed fluid therapy should be used to optimize volume status 2

Pain Management

• First-line: Oral NSAIDs for pain control 2
• Alternative/adjunct: Acetaminophen when NSAIDs are contraindicated 2

Biliary Drainage Options

For patients who are high-risk surgical candidates or temporarily unfit for surgery:

1. Percutaneous Transhepatic Gallbladder Drainage (PTGBD):

   • Preferred approach for high-risk patients 1, 2
   • Transhepatic approach recommended to reduce bile leakage risk 2
   • Duration typically 4-6 weeks 2
   • Complications: bile leakage, bleeding, catheter dislocation 2, 3

2. Endoscopic Drainage Options:

   • Endoscopic Transpapillary Gallbladder Drainage (ETGBD):

     • Performed via ERCP with placement of a double-pigtail stent 3
     • Particularly useful for patients with coagulopathy or thrombocytopenia 3
     • Preserves external gallbladder structure, facilitating future cholecystectomy 3

   • Endoscopic Ultrasound-Guided Gallbladder Drainage (EUS-GBD):

     • Uses plastic, fully covered metallic, or lumen-apposing metal stents 3
     • High technical and clinical success rates (80.9% and 97%, respectively) 2
     • Provides more permanent drainage than PTGBD or ETGBD 3
     • Recommended only in high-volume centers with skilled endoscopists 2

Non-Operative Management (NOM)

• Consider for patients refusing surgery or unsuitable for surgery 1
• Best medical therapy includes supportive care and observation 1
• Note: 30% of patients with mild acute cholecystitis who don't undergo cholecystectomy will develop recurrent gallstone-related complications 1, 2

Acute Cholangitis Management

Biliary Decompression

• Primary intervention: Endoscopic Retrograde Cholangiopancreatography (ERCP) 1
  • First-line treatment for Class A/B patients with acute cholangitis 1
  • For Class C patients, ERCP should be performed with antibiotic therapy 1

Supportive Care

• Fluid resuscitation and electrolyte correction 2
• Monitoring of vital signs and clinical status 1

Special Considerations

Gallstone Prevention

• Ursodeoxycholic acid is indicated for prevention of gallstone formation in obese patients experiencing rapid weight loss 4
• Also indicated for patients with radiolucent, noncalcified gallbladder stones <20mm who have increased surgical risk 4

Nausea and Vomiting Management

• Lorazepam 0.5-2 mg oral, IV, or sublingual every 4-6 hours as needed 2
• H2 blockers or proton pump inhibitors may be added 2
• Around-the-clock administration rather than PRN dosing 2
• For breakthrough nausea/vomiting, use agent from different drug class 2
• Consider rectal or IV route if oral route not feasible due to vomiting 2

Important Caveats

1. Non-operative management should be considered a bridge to surgery rather than definitive treatment due to high recurrence rates (up to 30%) 5, 2

2. Cholecystectomy remains the definitive treatment for acute cholecystitis in patients fit for surgery 1

3. Biliary drainage should be individualized based on:

   • Patient's clinical status and comorbidities 1
   • Local expertise and available resources 1, 3
   • Presence of coagulopathy or anatomical considerations 3

4. Preoperative biliary drainage is controversial but may be indicated in specific scenarios:

   • Major hepatectomy (>60% of total liver volume) with total bilirubin >200 μmol/L 1
   • Presence of cholangitis 1
   • Portal vein embolization (PVE) 1
   • Malnutrition 1

5. Risk factors for conversion to open cholecystectomy include male gender, previous upper abdominal surgery, and advanced age 1

By implementing these non-antibiotic management strategies, patients can be optimally prepared for definitive surgical management while minimizing complications and improving outcomes.