Infections of the gastro-intestinal tract

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Cholecystitis

Case report:

A 63-year-old female comes with lasting for three days right upper quadrant abdominal pain, fever up to 38.5 C, nausea and retching into practice. At times even diarrhea had occurred and temporarily slightly lighter colored chairs and dark urine. The patient reported that ultrasound a few months ago, two major gallbladder stones were detected in her, and she had taken in the days before the onset of symptoms relatively high fat foods to be. The physical examination provides a clear pressure pain in the upper right Abdominalquadranten at the lower edge of the liver.

Diagnosis:

The patient's symptoms and the sonographic findings as well as the clinical examination findings point to an acute cholecystitis. In blood there was a leukocytosis of 12,000 / ul with left shift in the differential blood count and increased to 35 mg / L CRP. Liver function parameters showed a moderate increase of cholestasis (GammaGT and alkaline phosphatase) at only slightly elevated transaminases.

Pathogenesis:

The cause of bladder infections in the bile majority of cases a cholecystolithiasis, rare tumors or an ascending infection from the intestine. The most commonly detected pathogens are Escherichia coli and Klebsiella spp. Often there is also a mixed infection, may be involved in up to 15% of cases anaerobes.

Therapy:

Since the patient does not seriously ill impression, is an empirical therapy - introduced in oral form - without blood cultures. This can be used if no penicillin allergy is known ampicillin plus sulbactam (UNACID) or amoxicillin plus clavulanic acid (Augmentin). Favorable results are also for ciprofloxacin (Cipro) ago. If the patient indicates to severe nausea, to perform oral therapy from the outset, parenteral treatment can be started with mezlocillin (BAYPEN) or piperacillin (PIPRIL), which certainly also beta-lactamase inhibitors should be administered with (in recurrent biliary infections). As an alternative, ceftriaxone (Rocephin) due to the favorable once-daily application of e.g. 2 g a therapeutic option. Once the patient can eat normal food again, should be converted to oral therapy. If symptoms persist after five to seven days, especially with continuous fever, an acute surgical intervention must be considered.

Surgical treatment recommendation:

Acute cholecystitis is a conservative antibiotic disease to be treated only in very exceptional cases and should be addressed immediately by surgery.
Even before the era of laparoscopic cholecystectomy, the professional association has recommended the earliest possible OP: the surgical risk and the duration of the disease can be considerably reduced. A conservative and quite possible even repeatedly treated cholecystitis with lithiasis has always been a tough test for the surgeon, and thus also for the patient because of adhesions. Endoscopic control this situation is doomed to fail more frequently. A fresh cholecystitis contrast can operate much easier by the oedematous separation of the layers, and the patient recovers without further antibiotic treatment.
Surgical treatment recommendation is unanimous for the immediate preparation for surgery within 24 - 48 hours. During the preparation time, of course, grab your recommendations for antibiotic treatment. An oral antibiotic therapy has no place in this concept, of course.

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