What is the management of a post-burn patient presenting with right upper quadrant (RUQ) pain, a dilated gallbladder (GB), thickened wall, and pericholecystic fluid?

From the Guidelines

The management for a postburn patient presenting with right upper quadrant pain, dilated gallbladder, thickened wall, and pericholecystic fluid would be option A: cholecystostomy tube placement. This approach is supported by the most recent guidelines, including the 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis 1. The patient's presentation suggests acalculous cholecystitis, a condition where the gallbladder is inflamed without the presence of gallstones, which is a known complication in critically ill patients, especially those with severe burns. Percutaneous cholecystostomy provides immediate gallbladder decompression and drainage, avoiding the risks of general anesthesia and surgical stress in an already compromised patient. Key points to consider in the management include:

• The procedure involves ultrasound-guided placement of a drainage catheter into the gallbladder to relieve pressure and drain infected bile.
• Broad-spectrum antibiotics covering enteric gram-negative organisms and anaerobes should accompany this procedure, such as piperacillin-tazobactam or a combination of a third-generation cephalosporin with metronidazole.
• Cholecystectomy (option B) carries higher risks in critically ill burn patients and is typically reserved for those who fail to improve with cholecystostomy or once the patient has stabilized.
• Antibiotics alone (option C) would be insufficient without addressing the mechanical obstruction and inflammation present in the gallbladder, as highlighted in guidelines for the management of intra-abdominal infections 1. The choice of cholecystostomy is further supported by its recognition as a safe and effective treatment for acute cholecystitis in critically ill and/or patients with multiple comorbidities who are unfit for surgery, as stated in the 2017 WSES guidelines for management of intra-abdominal infections 1.

From the Research

Management of Postburn Patient with RUQ Pain, Dilated GB, Thick Wall, and Pericholecystic Fluid

• The patient's presentation suggests acute cholecystitis, which requires prompt management to prevent further complications.
• According to the study by 2, cholecystostomy tubes can be used as a temporary treatment for acute cholecystitis in critically ill patients, with the goal of subsequent cholecystectomy when the patient is medically suitable.
• The study by 3 also supports the use of percutaneous cholecystostomy as an interventional alternative to cholecystectomy in certain circumstances, such as severely ill patients in intensive care.
• In terms of antibiotic use, the guidelines by 4 recommend the use of peri-operative antibiotic agents for patients undergoing laparoscopic cholecystectomy for acute cholecystitis.
• Considering the patient's condition, the most appropriate management option would be:
  • A: Cholecystostomy tube, as it provides immediate biliary drainage and can be used as a bridge to surgery or as a management option for patients who are not fit for surgery, as supported by 2, 3, and 5.
• Other options, such as cholecystectomy (B) and antibiotics (C), may also be considered, but the use of a cholecystostomy tube is the most appropriate initial management step in this scenario.