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4Cholelithiasis_complications.doc

In the past drainage was performed surgically today

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In the past, drainage was performed surgically. Today, options of percutaneous or endoscopic drainage exist in addition to medical management with antibiotics. Endoscopic drainage has been shown to decrease mortality rates from 30% to 10%. The mainstay of therapy is drainage. ERCP is the best method to accomplish biliary drainage. A novel technique that is being used in Asia in the surgical management of acute cholangitis is endoscopic nasobiliary drainage. 5
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Medication Summary The goal of antimicrobial therapy is to resolve the infection. Debate exists as to whether the most effective antibiotics must have high biliary concentrations. When high intrabiliary pressures exist due to biliary obstruction, whether any antibiotic is excreted effectively into the bile is doubtful, thus making biliary levels irrelevant. The choice of antibiotics should be guided by local sensitivity patterns. It is critical that antibiotics are administered early in the management of cholangitis. In the ED, empiric antibiotic therapy should cover against gram- negative aerobic enteric organisms (eg, E coli, Klebsiella species, Enterobacter species), gram-positive organisms (eg, Enterococcus and Streptococcus species), and anaerobes (eg, Bacteroides fragilis, Clostridium perfringens). Newer combinations have been shown to be effective as either a single agent or combination therapy. Combinations include extended-spectrum cephalosporin, metronidazole, and ampicillin. Single- agent regimens include piperacillin and tazobactam; mezlocillin; imipenem; meropenem; ticarcillin and clavulanate; or ampicillin and sulbactam, which can also be combined with metronidazole. In patients with few comorbidities and who are well-appearing, using a single agent such as cefoxitin (second- generation cephalosporin) may be appropriate. 6
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GALLBLADER HYDROPS AND EMPYEMA Background Mucocele, or hydrops, of the gallbladder describes an overdistended gallbladder filled with mucoid or clear and watery content. The condition can result from gallstone disease, the most common affliction of the biliary system. The gallbladder mucocele distension, which is usually noninflammatory, results from an outlet obstruction of the gallbladder and is commonly caused by an impacted stone in the neck of the gallbladder or in the cystic duct. Epidemiology Frequency About 3% of all pathologic gallbladders in adults are mucoceles. The true prevalence may be higher because of the varying criteria used by different authors to define the condition. Reports indicate that an association could exist between mucoceles and solitary stones of the gallbladder. Etiology Causes of gallbladder mucocele include the following: Impacted stone in the gallbladder neck or cystic duct Spontaneously resolved acute cholecystitis Tumors - Polyps or malignancy of the gallbladder Extrinsic compression of the neck or cystic duct by lymph nodes or inflammatory fibrosis or by adjacent malignancies in the liver, duodenum, or colon Congenital narrowing of the cystic duct Parasites, such as Ascaris (occasionally) Pathophysiology Long-standing obstruction to the gallbladder's outflow results in
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  • Winter '18
  • Jane doe
  • Digestive System, bile duct, Hepatology, Gallstone

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