Therapeutic targets
- Freedom from symptoms
- Elimination of pathogens, if necessary (as far as bacterial cholecystitis is present; about 85% of cases).
- Avoidance of complications
Therapy recommendations
- Analgesia (pain relief) for biliary colic, depending on the severity of colic:
- For mild colic, prefer butylscopolamine (parasympatholytic), rectal (“into the rectum“), or parenteral (“bypassing the intestine”) administration and/or use glycerol trinitrate plus an analgesic (e.g., acetaminophen or metamizole)
- In severe colic, combine metamizole and butylscopolamine and an opioid analgesic Cave! Do not use opioid analgesics other than pethidine or buprenorphine! due torisk of sphincter Oddi spasm (spasm of the sphincter muscle at the mouth of the bile duct in the duodenum).
- In addition to drug therapy should be observed for at least 24 h food abstinence (abstention from food), then low-fat diet.
- Antibiosis (antibiotic administration) if bacterial cholecystitis is suspected:
- Note: Empiric therapy must be de-escalated (lower dosage, discontinuation of individual agents) as soon as culture results are available; duration of therapy should be kept as short as possible.
- Choice of antibiotic taking into account the following criteria: Target organisms, local resistance situation, pharmacokinetics and pharmacodynamics, liver function, previous antibiotic therapy, allergies, and other possible adverse events.
- Ampicillin + sulbactam (acylaminopenicillin + ß-lactamase inhibitor) [first-line agent]; for septic course and high-risk patients: Antibiotic therapy with piperacillin + tazobactam.
- Duration of therapy (see below Tokyo Guidelines 2018):
- For patients with grade I or II acute cholecystitis, antimicrobial therapy is recommended only before and at the time of surgery.
- For patients with grade III, antibiotic treatment should still be given for four to seven days postoperatively.
- For patients with pericholecystic abscess (pus cavity in the gallbladder area) or gallbladder perforation (rupture of the gallbladder), antimicrobial therapy should be continued until the patient is afebrile, the leukocyte (“white blood cell”) count is within the normal range, and abdominal findings (findings of the abdominal organs) are no longer present
- Laparoscopic cholecystectomy (gallbladder removal by laparoscopy; see under “Surgical Therapy”).
- See also under “Further therapy.”
Analgesics Analgesics are painkillers. There are several different subgroups, such as the NSAIDs (non-steroidal anti-inflammatory drugs) to which ibuprofen and ASA (acetylsalicylic acid) belong, or else the group around the non-acid analgesics paracetamol and metamizole. They are all widely used. Many preparations in these groups carry a risk of gastric ulcers (stomach ulcers) with prolonged use.
Spasmolytics Spasmolytics are antispasmodic drugs. They are divided into several subgroups and are used for bronchial asthma, renal and biliary colic, and gastrointestinal spasms, among other conditions. The most important representatives are butylscopolamine and scopolamine.
Antibiotics Antibiotics are drugs that are administered when an infection with a bacterium is present. They act either bacteriostatically, inhibiting the growth of the bacteria, or bactericidally, killing the bacteria.
