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clinical evaluation, then cholescintigraphy (99mTc-hepatobiliary iminodiacetic acid, HIDA scan) is

recommended and nonvisualization of the gallbladder confirms acute cholecystitis with sensitivity of

96% and specificity of 90% (Algorithm 8-2).24

Early systemic antimicrobial treatment is indicated for acute cholecystitis to cover the causative

pathogens, including aerobic, enteric, gram-negative bacilli (i.e., E. coli, Klebsiella, Enterobacter, and

Proteus), and aerobic gram-positive organisms (i.e., Enterococcus and Streptococcus). Anaerobes are

uncommon, identified in approximately 15% of isolates. Clostridial organisms can be identified in cases

of emphysematous cholecystitis confirmed by identification of gas in the gallbladder wall.

Cholangitis

Cholangitis signs/symptoms include jaundice, fever, right upper quadrant tenderness,

hyperbilirubinemia, and leukocytosis. Ultrasound confirms common bile duct dilation (>7 mm).

Appropriate evidence-based recommendations for diagnosis and treatment from the Tokyo Guidelines

are provided in Tables 8-6 and 8-7. For treatment recommendations, urgent biliary drainage (<24

hours) is indicated when (1) obstructive biliary stones are associated with severe or moderate acute

cholangitis OR (2) mild acute cholangitis is not responding to IV antibiotics and fluid resuscitation.

For patients with biliary infections, specific evidence-based guideline recommendations for

antimicrobial treatment are classified into four patient populations (Table 8-8). For patients undergoing

cholecystectomy for acute cholecystitis with complete source control (i.e., complete cholecystectomy),

antimicrobial therapy should be discontinued within 24 hours of the operation unless there is evidence

of infection outside the wall of the gallbladder. See also chapter on Calculous Biliary Disease.

Table 8-6 Diagnosis of Cholangitis: Tokyo Guidelines 2013

Table 8-7 Treatment of Acute Cholangitis by Severity Classification: Tokyo

Guidelines 2013 Criteria

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Diverticulitis

Diverticulitis is a common intra-abdominal infection. Its pathophysiology is associated with altered gut

motility, increased luminal pressure, and an altered colonic microenvironment.

Uncomplicated diverticulitis is treated with systemic antibiotics and usually resolves. Antimicrobial

treatment of diverticulitis is the same as for cIAI which is reviewed above. In a cohort study of 2,366

patients hospitalized in the Kaiser Permanente system and followed for 8.9 years, only 13.3% had a first

recurrence and 3.9% had a second recurrence.25

Surgery for acute diverticulitis is indicated for patients who present with peritonitis and/or sepsis or

who do not improve with medical management and/or percutaneous drainage of associated

abscess/infection. Although less than 25% of patients will develop generalized peritonitis after colonic

perforation, it is severe with high mortality. Surgical options include simple colostomy formation in the

setting of profound inflammation (rarely performed), traditional sigmoid resection with colostomy

(Hartmann procedure), and sigmoid resection with a primary colocolonic or colorectal anastomosis with

or without a diverting loop ileostomy. Laparoscopic surgery is preferred to open surgery when

possible.26

Table 8-8 Antimicrobials for Treatment of Biliary Infections

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Figure 8-1. Hinchey classification scheme. Patients with stage 1 disease have small, confined, pericolic, or mesenteric abscesses,

whereas those with stage 2 disease have larger abscesses, often confined to the pelvis. Stage 3 disease, or perforated diverticulitis,

is present when a peridiverticular abscess has ruptured and caused purulent peritonitis. Rupture of an uninflamed and unobstructed

diverticulum into the free peritoneal cavity with fetal contamination, the so-called free rupture, signifies stage 4 disease and carries

the highest risk of an adverse outcome.

Since recurrence after recovery from an uncomplicated episodes of diverticulitis is rare and two or

more recurrences are not associated with increased risk of complications, elective colectomy following

two episodes of diverticulitis is no longer recommended. Decisions regarding surgical intervention and

colectomy must therefore be based on individual potential risks and benefits of colon resection.27

For patients who require surgical intervention, the specific treatment that is associated with the best

outcome is controversial. Hinchey proposed a practical clinical classification of diverticulitis based on

the severity of peritoneal contamination (Fig. 8-1) identified at operation.28 The modified Hinchey

classification includes Hinchey Ia (confined pericolic inflammation–phlegmon) and Ib (confined pericolic

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abscess) and considers classification based on radiologic imaging with CT scan as well. Increasing

Hinchey classification is associated with increased mortality. The mortality for patients with Hinchey III

is reported as 6% but increases greatly to 35% for fecal peritonitis (Hinchey IV). A systematic review

comparing surgical treatments for Hinchey III or IV colonic diverticulitis confirmed that primary

resection with anastomosis has a significant advantage with lower mortality compared to Hartmann

procedure. Furthermore, laparoscopic peritoneal lavage with subsequent surgical resection if indicated

had lower surgical morbidity and hospital length of stay compared to the primary resection and

anastomosis group.29 See also chapter on Diverticular Disease.

Figure 8-2. Treatment of initial episode of Clostridium difficile infection.

Clostridium Difficile Colitis

The incidence and severity of Clostridium difficile infection (CDI) has increased, particularly in surgical

patients who have been exposed to prior antimicrobial therapy. There has been a substantial change in

the management of CDI related to the emergence of the NAP1/BI/027 strain which is associated with

higher toxin production and more severe forms of disease. CDI may be associated with mild to

moderate diarrhea or colonic ileus and obstipation to severe colitis.30

Early diagnosis of CDI is imperative. Recommended testing includes two steps, using a glutamine

dehydrogenase assay for the Clostridium difficile antigen, followed by enzyme immunoassay toxin

testing. Polymerase chain reaction (PCR) confirmatory testing is used if the antigen is positive and toxin

is negative.31 Radiologic testing is helpful, and CT may show colonic mucosal edema (thumbprinting or

target sign), ascites, inflammation, and fat stranding and the “accordion sign” which indicates

alternating edematous colonic haustra separated by transverse mucosal ridges filled with enteral

contrast.

Initial management of CDI is cessation of all antibiotics if possible. The 2010 SHEA/IDSA guidelines

have evidence-based recommendations for CDI based on severity of disease (Fig. 8-2).32 Vancomycin

and metronidazole are first-line therapy. Vancomycin is preferred for severe or complicated disease.

Fidaxomicin (a macrocyclic antibiotic with a narrow antimicrobial spectrum against C. difficile,

staphylococci, and enterococci) may be considered for recurrent CDI or where risk of recurrence is high.

A multicenter multinational randomized trial confirmed decreased recurrence rates compared to oral

vancomycin and it is the U.S. Food and Drug Administration (FDA) approved with a recommended

treatment dose of 100 mg po bid.33 Fecal microbiota transplantation is associated with symptom

resolution and may be effective in recurrent CDI, but has no role in primary CDI treatment.

9 CDI may warrant surgical intervention. Surgical consultation should occur very early in the course

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