Gallstone Disease: Initial Management

• Cholelithiasis = gallstone
• Choledocholithiasis = presence of gallstones within the common bile duct

Managing gallbladder stones

• Reassure people with asymptomatic gallbladder stones found in a normal gallbladder and normal biliary tree that they do not need treatment unless they develop symptoms.
• Offer laparoscopic cholecystectomy to people diagnosed with symptomatic gallbladder stones.
• Offer early laparoscopic cholecystectomy (to be carried out within 1 week of diagnosis) to people with acute cholecystitis.
• Offer percutaneous cholecystostomy to manage gallbladder empyema when:

• surgery is contraindicated at presentation and
• conservative management is unsuccessful.

• Reconsider laparoscopic cholecystectomy for people who have had percutaneous cholecystostomy once they are well enough for surgery.

Managing common bile duct stones

• Offer bile duct clearance and laparoscopic cholecystectomy to people with symptomatic or asymptomatic common bile duct stones.
• Clear the bile duct:

• surgically at the time of laparoscopic cholecystectomy or
• with endoscopic retrograde cholangiopancreatography (ERCP) before or at the time of laparoscopic cholecystectomy.

• If the bile duct cannot be cleared with ERCP, use biliary stenting to achieve biliary drainage only as a temporary measure until definitive endoscopic or surgical clearance.
• Use the lowest‑cost option suitable for the clinical situation when choosing between day‑case and inpatient procedures for elective ERCP.

Bile Salt Therapy (ursodeoxycholic acid)

• Suppress hepatic cholesterol secretion and inhibit intestinal absorption of cholesterol. It solubilizes cholesterol in micelles and acts by dispersing cholesterol in aqueous media
• Medical management is more effective in patients with good gallbladder function who have small stones (< 1 cm) with a high cholesterol content. 
• Bile salt therapy may be required for more than 6 months and has a success rate less than 50%.

Patient, family member and carer information

• Advise people to avoid food and drink that triggers their symptoms until they have their gallbladder or gallstones removed.
• Advise people that they should not need to avoid food and drink that triggered their symptoms after they have their gallbladder or gallstones removed.

References: 

1. https://www.nice.org.uk/guidance/cg188/chapter/1-Recommendations
2. http://emedicine.medscape.com/article/175667-treatment#d11

Thyphoid Vaccinations

• Availability: Vi polysaccharide thyphoid vaccine, IV

Indication

• recommended for travelers (even short-term travelers) to areas where there is risk of exposure to S. typhi
• individuals with intimate exposure to a documented S. typhi chronic carrier (eg, household contacts),
• individuals whose work exposes them to cultures or specimens containing S. typhi (eg, laboratory workers)

Effectiveness:

• parenteral Vi polysaccharide vaccine was useful for inducing both direct and indirect protection (overall protection was 57 percent)
• Vaccination may be considered even after clinical illness, particularly in those not living in endemic areas, if re-exposure is expected
• Natural infection does not provide complete protection against recurrent illness (which is not the same as relapsed infection).

Contraindications or need to wait if

• Should not be given to children younger than 2 years of age.
• Anyone who has had a severe reaction to a previous dose of this vaccine should not get another dose.
• Anyone who has a severe allergy to any component of this vaccine should not get it. Tell your doctor if you have any severe allergies.
• Anyone who is moderately or severely ill at the time the shot is scheduled should usually wait until they recover before getting the vaccine.

Pregnancy

• Avoid oral vaccine which contains life vaccine
• Inadequate data for specific recommendation for IV Thyphoid vaccine
• As it is not critical for management of disease, can consider delaying vaccination till pregnancy is over

BreastFeeding

• There is no known risk to your baby if you are vaccinated with the typhoid vaccine while you are breastfeeding 

References:

1. Product Leaflet
2. http://www.cdc.gov/vaccines/pubs/preg-guide.htm#21
3. http://www.cdc.gov/vaccines/vpd-vac/should-not-vacc.htm#typhoid

Quick Comparison Between Antiplatlet

Side Effects:

• all antiplatelet drugs increase the risk of bleeding in the gastrointestinal tract and brain
• Clopidogrel (Plavix), prasugrel (Effient) and ticlopidine (Ticlid) have been linked to a condition known as thrombotic thrombocytopenic purpura (TTP)
• ticlopidine (Ticlid and generic) have a risk for TTP that’s much higher than those taking clopidogrel or prasugrel
• The danger of getting any of the three conditions—TTP, neutropenia, and aplastic anemia—is highest during the first three months of taking ticlopidine
• Clopidogrel and ticlopidine can also interact adversely with other medicines

Indications:

 

 References:

1. Using Antiplatelet Drugs to Treat: Heart Disease, Heart Attacks, and Strokes Comparing Effectiveness, Safety, and Price
2. Comparison of Oral Antiplatelets. PHARMACIST’S LETTER / PRESCRIBER’S LETTER
   August 2014

Infected Bed Sore

 General

Superficial Infections: Topical Antibiotic

• Several topical antimicrobial agents reduce bacterial counts without damaging the wound, including silver sulfadiazine 1 percent cream, and other silver compounds
• Some antiseptic agents, including povidone-iodine, peroxide, and chlorhexidine gluconate, are cytotoxic to human fibroblasts, can delay healing, and should not be used
• Silver-containing dressings have been gaining popularity but their efficacy remains to be determined
• Topical antibiotics are generally no longer recommended due to concerns about side effects and development of resistance
• The routine use of medicated dressings in other circumstances is probably not indicated
• A one to two week trial of topical antiseptics is reasonable for clean pressure ulcers that fail to heal after two to four weeks of optimal care .
• If there is no improvement, further work-up should be pursued, including a soft tissue biopsy for culture and evaluation for underlying osteomyelitis

Deep Infections

• Deep infection includes ulcers complicated by cellulitis, osteomyelitis, bacteremia, and/or sepsis, and requires systemic antimicrobial therapy
• Management is based on the culture, site and type of infection
• Because such infections usually are polymicrobial, therapeutic regimens should be directed against both gram-positive and gram-negative facultative organisms as well as anaerobic organisms

Systemic Antibiotic:

• Systemic antibiotic therapy is required for patients with bacteraemia, sepsis, advancing cellulitis, or osteomyelitis.
• Systemic antibiotics are not required for pressure ulcers that exhibit only signs of local infection. 
• In patients due for surgery, it is necessary to review the microbiological status of the wound and provide systemic antimicrobial cover where appropriate

References:

1. BMJ
2. www.uptodate.com
3. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.
4. Infected Pressure Ulcers in Elderly Individuals. Clin Infect Dis. (2002) 35 (11): 1390-1396

Acute Cholecystitis Treatment

Empiric antibiotic therapy for gram-negative and anaerobic pathogens ^1,2

Regimen	Dose (adult)
First choice
Monotherapy with a beta-lactam/beta-lactamase inhibitor:
*Ampicillin-sulbactam	3 g IV q6h
Piperacillin-tazobactam	3.375 or 4.5 g IV q6h
Ticarcillin-clavulanate	3.1 g IV q4h
**Combination third generation cephalosporin PLUS metronidazole:
Ceftriaxone plus	1 g IV q24h
Metronidazole	1g loading dose followed by 500 mg IV q6h
Alternative empiric regimens
***Combination fluoroquinolone PLUS metronidazole
Ciprofloxacin or	400 mg IV q12h
Levofloxacin plus	500 or 750 mg IV q24h
Metronidazole	500 mg IV q8h
Monotherapy with a carbapenem:
Imipenem-cilastatin	500 mg IV q6h
Meropenem	1 g IV q8h
Doripenem	500 mg IV q8h
Ertapenem	1 g IV q24h

Comments :

According to NAG 2014;

*First line treatment

**Alternative treatment

***Alternative to severe penicillin allergy

• For complicated acute cholecytitis, duration= 4-7 days unless adequate source control is not achieved.
• For uncomplicated acute cholecytis, antibiotics should be given until biliary obstruction is relieved. No post-procedure antibiotic antibiotics are necessary if the obstruction is successfully relieved.

References:

1. NAG
2. Up-To-Date
3. Sanford