What is the optimal management plan for a 60-year-old diabetic lady with known gallstone disease, presenting with severe right upper quadrant (RUQ) pain, anorexia, jaundice, and general weakness, and found to have a distended, non-tender gallbladder filled with pus and peritoneal nodules on abdominal computed tomography (CT) scan?

Management of a 60-year-old Diabetic Patient with Gallstone Disease and Peritoneal Nodules

Cholecystostomy and biopsy (option C) is the optimal management plan for this 60-year-old diabetic lady with gallstone disease presenting with severe RUQ pain, anorexia, jaundice, and a distended gallbladder filled with pus and peritoneal nodules on CT scan.

Clinical Assessment and Rationale

This patient presents with several concerning features:

• Severe RUQ pain, anorexia, jaundice, and general weakness
• CT findings of distended gallbladder filled with pus
• Presence of peritoneal nodules
• History of diabetes and gallstone disease

The presence of peritoneal nodules is particularly concerning as it suggests possible malignancy. The distended gallbladder filled with pus indicates empyema of the gallbladder, which requires urgent decompression.

Why Cholecystostomy and Biopsy is Preferred:

1. Presence of Peritoneal Nodules: The peritoneal nodules strongly suggest malignancy, which requires histological confirmation before definitive treatment 1.

2. Gallbladder Empyema: The gallbladder filled with pus indicates empyema requiring urgent drainage to control sepsis 2.

3. Patient Risk Profile: As a 60-year-old diabetic patient with jaundice, she falls into a high-risk category where percutaneous cholecystostomy is recommended as a safer initial approach 2.

4. Diagnostic and Therapeutic Value: Cholecystostomy provides both drainage of the infected gallbladder and allows for tissue sampling of the peritoneal nodules to guide further management 2, 1.

Why Other Options Are Less Suitable:

• Cholecystojejunostomy (A): This is a palliative procedure for biliary obstruction but does not address the need for diagnosis of the peritoneal nodules and may spread infection if malignancy is present.

• En bloc resection of the mass (B): Without histological confirmation of malignancy, this aggressive approach is premature and carries unnecessary risks in a patient with active infection.

• Palliative cholecystectomy (D): While this might be considered after diagnosis, it's not appropriate as the initial step without knowing the nature of the peritoneal nodules and in the setting of acute infection 3.

Management Algorithm

1. Initial Stabilization:

   • Fluid resuscitation
   • Antibiotic therapy for biliary sepsis
   • Pain management

2. Percutaneous Cholecystostomy:

   • Ultrasound-guided drainage of the gallbladder to relieve the empyema
   • This serves as a bridge to definitive treatment 2

3. Biopsy of Peritoneal Nodules:

   • CT or ultrasound-guided biopsy of peritoneal nodules
   • Histopathological examination with immunohistochemistry

4. Further Management Based on Biopsy Results:

   • If malignancy confirmed: Staging and appropriate oncological management
   • If gallbladder carcinoma: Consider palliative cholecystectomy if feasible 3
   • If neuroendocrine carcinoma: Consider radical resection with adjuvant chemotherapy 4
   • If benign process: Plan for interval cholecystectomy after resolution of acute inflammation

Important Considerations

• Antibiotic Therapy: The World Journal of Emergency Surgery recommends broad-spectrum antibiotics for complicated biliary infections, particularly in diabetic patients 2, 1.

• Timing of Definitive Surgery: If malignancy is ruled out, definitive cholecystectomy should be performed after resolution of the acute inflammatory process, typically within 45 days 1.

• Monitoring: Close monitoring for resolution of sepsis is essential, with continuation of antibiotics for 4-7 days depending on clinical response 1.

• Potential for Conversion: If cholecystostomy improves the patient's condition and malignancy is ruled out, laparoscopic cholecystectomy may be attempted, though the conversion rate to open surgery may be higher in these complex cases 5.

This approach balances the need for urgent management of the empyema while obtaining crucial diagnostic information about the peritoneal nodules, which will guide definitive treatment in this high-risk patient.