What is the most appropriate next action for a patient with severe abdominal pain, hypotension, and signs of sepsis, with lab results indicating lactic acidosis, leukocytosis, and hyperbilirubinemia, and imaging showing free intraperitoneal fluid and a gallbladder wall defect?

Management of Gallbladder Perforation with Peritonitis and Sepsis

The most appropriate next action for this critically ill patient with gallbladder perforation, peritonitis, and septic shock is to consult general surgery for emergency laparotomy with cholecystectomy.

Clinical Assessment and Diagnosis

This 68-year-old male presents with classic signs of gallbladder perforation:

• Severe right upper quadrant pain
• Abdominal rigidity with rebound tenderness and guarding
• Hypotension and tachycardia (signs of shock)
• Laboratory findings: rising lactic acidosis, leukocytosis, hyperbilirubinemia
• Imaging: free intraperitoneal fluid, pericholecystic fluid, and gallbladder wall defect on CT

These findings represent a type I gallbladder perforation (free perforation with generalized peritonitis) which is a surgical emergency requiring immediate intervention 1.

Management Algorithm

1. Immediate Surgical Consultation

   • Emergency laparotomy with cholecystectomy is the definitive treatment for gallbladder perforation with peritonitis 1
   • Delayed surgical intervention is associated with increased morbidity, mortality, ICU admission, and prolonged hospitalization 1

2. Concurrent Resuscitation Measures (while awaiting surgery)

   • IV fluid resuscitation
   • Broad-spectrum antibiotics
   • Vasopressors if needed to maintain MAP ≥65 mmHg

3. Surgical Approach

   • Right colectomy with terminal ileostomy should be considered if significant contamination is present 1
   • In severely unstable patients with overwhelming sepsis, damage control surgery with open abdomen may be considered 1

Why Surgery Takes Priority

Gallbladder perforation with peritonitis represents a surgical emergency where source control is paramount. The World Society of Emergency Surgery guidelines clearly state that "early diagnosis of gallbladder perforation and immediate surgical intervention may substantially decrease morbidity and mortality rates" 1.

The reported mortality in gallbladder perforation cases is as high as 12-16% 1, making immediate surgical intervention critical. This patient's clinical presentation with hypotension, tachycardia, and lactic acidosis indicates septic shock, which further emphasizes the need for immediate source control through surgery.

Pitfalls to Avoid

• Delaying surgery for prolonged resuscitation: While resuscitation is important, delaying source control in peritonitis worsens outcomes. Azuhata et al. demonstrated 0% survival when time to surgery exceeded 6 hours in GI perforation with septic shock 1.

• Relying solely on medical management: Medical management alone (antibiotics, fluids, vasopressors) without surgical source control is inadequate for gallbladder perforation with peritonitis.

• Underestimating the urgency: Type I gallbladder perforation with generalized peritonitis requires immediate surgical intervention, as delayed treatment significantly increases mortality 1.

Antibiotic Considerations

While arranging for emergency surgery, broad-spectrum antibiotics should be initiated:

• Piperacillin/tazobactam, imipenem/cilastatin, meropenem, ertapenem, or aztreonam are recommended 1
• In cases of shock, add amikacin 1
• For fragile patients or delayed diagnosis, consider adding fluconazole 1

Special Considerations

In this patient with multiple comorbidities (sarcoidosis on chronic steroids, cirrhosis, CAD, DMII), the risk of surgical complications is higher. However, the presence of gallbladder perforation with peritonitis and septic shock makes emergency surgery the only viable option for survival.

The presence of cirrhosis increases the surgical risk but does not contraindicate emergency surgery when life-threatening conditions like gallbladder perforation with peritonitis are present.