What is the best course of treatment for a patient with recurrent right upper quadrant abdominal pain and possible cholecystitis?

Management of Recurrent Right Upper Quadrant Pain with Possible Cholecystitis

Laparoscopic cholecystectomy is strongly recommended as the definitive treatment for this patient with recurrent right upper quadrant pain and possible cholecystitis, despite negative leukocytes and liver function tests. 1

Clinical Assessment and Diagnosis

The patient presents with:

• Recurrent right upper quadrant (RUQ) abdominal pain
• Previous episode 2 months ago with similar presentation
• Positive Murphy's sign on both occasions
• Ultrasound findings suggestive of cholecystitis on both occasions
• Negative HIDA scan during first episode
• No leukocytosis or liver function test abnormalities on either occasion
• Previous treatment with antibiotics without surgical intervention

This presentation is consistent with recurrent acute cholecystitis, despite the absence of leukocytosis. The positive Murphy's sign and ultrasound findings are significant diagnostic indicators, even in the absence of laboratory abnormalities.

Treatment Algorithm

First-line Treatment:

• Early laparoscopic cholecystectomy (within 7-10 days of symptom onset) 1, 2
  • Offers definitive treatment
  • Prevents further recurrences
  • Associated with fewer complications compared to delayed intervention
  • Shorter hospital stays and lower costs compared to non-operative management

For Patients Unfit for Surgery:

1. Medical management with antibiotics 1, 2

   • For non-critically ill patients: Amoxicillin/Clavulanate 2g/0.2g q8h
   • For beta-lactam allergies: Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose then 50 mg q12h
   • Duration: 4-7 days based on clinical response

2. Consider percutaneous cholecystostomy as a temporary measure if medical management fails 1

   • Note: This is inferior to cholecystectomy in terms of major complications and should be reserved for patients truly unfit for surgery

Evidence-Based Rationale

The 2020 World Society of Emergency Surgery guidelines strongly recommend early laparoscopic cholecystectomy for acute cholecystitis, including recurrent cases 1. This approach is superior to observation and antibiotic therapy alone, as approximately 30% of patients with acute cholecystitis who do not undergo cholecystectomy will develop recurrent gallstone-related complications 1.

The Italian Council for Optimization of Antimicrobial Use (2024) also supports early surgical intervention, noting that delayed treatment is associated with higher complication rates 1. Even in high-risk patients, laparoscopic cholecystectomy has been shown to be superior to gallbladder drainage procedures 1.

Special Considerations

1. Negative leukocytosis and normal LFTs do not rule out cholecystitis

   • The ACR Appropriateness Criteria notes that clinical and imaging findings may be sufficient for diagnosis even without laboratory abnormalities 1
   • Ultrasound findings of gallbladder wall thickening, pericholecystic fluid, and positive Murphy's sign are highly suggestive of cholecystitis

2. Negative HIDA scan

   • While HIDA scans typically have high sensitivity for acute cholecystitis, false negatives can occur
   • The combination of clinical symptoms, positive Murphy's sign, and ultrasound findings still strongly supports the diagnosis of cholecystitis

3. Recurrent nature of symptoms

   • The recurrence after antibiotic treatment without definitive surgical management is typical of gallstone disease
   • Studies show that patients who receive only medical management have high rates of symptom recurrence 1, 3

Pitfalls to Avoid

1. Relying solely on laboratory values to rule out cholecystitis

   • Normal WBC and LFTs do not exclude the diagnosis when clinical and imaging findings are suggestive

2. Repeated antibiotic courses without definitive treatment

   • This approach leads to recurrent episodes, antibiotic resistance, and potential complications

3. Delaying surgical intervention

   • Early cholecystectomy (within 7-10 days) is associated with better outcomes than delayed intervention 1, 3

4. Overlooking alternative diagnoses

   • If cholecystectomy is not performed and symptoms persist, consider additional imaging such as CT with IV contrast or MRCP to evaluate for other causes of RUQ pain 1

By proceeding with laparoscopic cholecystectomy, the patient will receive definitive treatment for their recurrent symptoms, preventing future episodes and potential complications of gallstone disease.