Should an 85-year-old male with symptoms of chill, nausea, vomiting, and generalized abdominal discomfort, possibly indicating acute cholecystitis, be transferred to the emergency room?

From the Guidelines

This 85-year-old male should be transferred to the emergency room for further evaluation and management of possible acute cholecystitis. Despite the patient currently appearing non-toxic with normal vital signs, soft abdomen, and no apparent distress, the combination of symptoms (chills, nausea, vomiting, and generalized abdominal discomfort) along with CT findings suggesting acute cholecystitis warrants emergency evaluation. Acute cholecystitis in elderly patients can progress rapidly and may present with subtle or atypical symptoms initially. The patient's advanced age increases his risk for complications such as gallbladder perforation, sepsis, or gangrenous cholecystitis. Emergency department evaluation would allow for prompt administration of IV antibiotics (such as piperacillin-tazobactam, ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole), adequate IV hydration, pain management, and surgical consultation. Laboratory tests including complete blood count, liver function tests, lipase, and blood cultures should be obtained. Even though the patient appears stable now, the natural course of cholecystitis often involves worsening inflammation, and early intervention is associated with better outcomes, particularly in elderly patients who have less physiological reserve to tolerate prolonged inflammation or infection, as suggested by the 2023 guidelines on source control in emergency general surgery 1.

The diagnosis of acute cholecystitis is made on the basis of clinical features such as right upper quadrant pain, fever, and leukocytosis and is supported by findings from relevant imaging studies, with ultrasound being the investigation of choice in patients suspected of having acute cholecystitis 1. The patient's symptoms and CT findings are consistent with acute cholecystitis, and further evaluation in the emergency department is necessary to confirm the diagnosis and initiate appropriate treatment.

The management of acute cholecystitis in elderly patients involves a multidisciplinary approach, including surgical consultation, and the patient's advanced age and potential comorbidities should be taken into consideration when determining the best course of treatment, as outlined in the 2019 guidelines on acute calcolous cholecystitis in elderly population 1. Percutaneous cholecystostomy may be an option in critically ill patients with multiple comorbidities and unfit for surgery or patients who do not show clinical improvement after antibiotic therapy for 3–5 days, as suggested by the 2023 guidelines on source control in emergency general surgery 1.

In terms of treatment, early cholecystectomy is a safe treatment for acute cholecystitis and generally results in shorter recovery time and hospitalization compared to delayed cholecystectomies, as reported in the 2017 guidelines for the management of intra-abdominal infections 1. Laparoscopic cholecystectomy is a safe and effective treatment for acute cholecystitis, and it is the first choice for patients with acute cholecystitis where adequate resources and skill are available, as stated in the 2017 guidelines for the management of intra-abdominal infections 1.

Overall, the patient's condition warrants prompt evaluation and treatment in the emergency department to prevent potential complications and improve outcomes.

From the Research

Patient Assessment

• The patient is an 85-year-old male presenting with symptoms of chill, nausea, vomiting, and generalized abdominal discomfort.
• A CT abdomen suggests possible acute cholecystitis.
• The patient is not in distress, non-toxic, with normal vitals, and has a soft and tender abdomen.

Considerations for Transfer to Emergency Room

• According to 2, laparoscopic cholecystectomy performed within 3 days of diagnosis is the first-line therapy for acute cholecystitis in most patient populations.
• However, the patient's age and potential comorbidities may affect the decision to transfer to the emergency room.
• 3 reports a case of a 77-year-old male with severe aortic stenosis who was managed non-surgically with a cholecystostomy tube due to high perioperative risk.
• 4 highlights the importance of preoperative risk prediction, with severe sepsis being a significant factor associated with postoperative morbidity and mortality.

Transfer Decision

• Given the patient's stable condition and lack of severe symptoms, transfer to the emergency room may not be immediately necessary.
• However, close monitoring and further evaluation are crucial to determine the best course of action.
• Consideration should be given to the patient's overall health status, potential comorbidities, and the risk of complications associated with acute cholecystitis, as discussed in 5, 2, 4, 6.