From the Guidelines
The best next step in this case is surgical removal of the gallbladder (option A). This patient presents with signs and symptoms highly suggestive of acute cholecystitis, including right upper quadrant abdominal pain, fever, tachycardia, leukocytosis, and a crackling sound in the right upper abdomen which may indicate emphysematous cholecystitis (gas in the gallbladder wall) 1. The presence of fever, tachycardia, and hypotension suggests progression to sepsis. While antibiotics are appropriate to start immediately, definitive treatment requires removal of the infected gallbladder. Delaying surgery until normalization of laboratory values (option C) would be dangerous in this case as the patient shows signs of systemic inflammatory response.
- Key points to consider:
- Early cholecystectomy (within 24-72 hours of presentation) is associated with decreased morbidity, shorter hospital stays, and lower costs compared to delayed intervention in acute cholecystitis 1.
- Interventional radiology drainage (option B) might be considered in patients who are poor surgical candidates, but this relatively healthy 62-year-old with controlled comorbidities would benefit most from definitive surgical treatment.
- ERCP (option D) would be more appropriate if the primary concern was common bile duct obstruction rather than gallbladder inflammation.
- The current guidelines recommend early laparoscopic cholecystectomy (ELC) as the treatment of choice for acute cholecystitis, as it is associated with lower hospital costs, fewer work days lost, and greater patient satisfaction 1.
- The patient's condition and the current evidence support the recommendation for early surgical removal of the gallbladder (option A), as it is the most effective treatment for acute cholecystitis and can help prevent further complications and improve outcomes 1.
From the Research
Patient Evaluation
The patient is a 62-year-old man with right upper abdominal pain, nausea, and vomiting, suspected of having cholecystitis. He has a history of hypertension, hypercholesterolemia, and well-controlled type 2 diabetes mellitus. His temperature is 38.5 C, pulse rate is 104 per minute, respirations are 18 per minute, and blood pressure is 106/58 mm Hg. He has significant right upper abdominal tenderness but no rebound tenderness. Leukocyte count is 19,000 [4000-11,000/pL].
Treatment Options
- The patient has been started on broad-spectrum antibiotics, and the next step is to be determined.
- Options include:
- Surgical removal of the gallbladder
- Placement of a drain by interventional radiology
- Gallbladder removal after the leukocyte count and temperature normalize
- Endoscopic retrograde cholangiopancreatography
Recommended Approach
Based on the studies 2, 3, 4, 5, 6, the recommended approach for the patient is:
- Laparoscopic cholecystectomy is the best treatment for acute cholecystitis and should be performed within 72 hours of diagnosis 4, 5, 6.
- However, for patients with severe comorbidities or high perioperative risk, percutaneous cholecystostomy may be considered as an alternative emergency treatment 2, 4, 5.
- In this case, since the patient has significant right upper abdominal tenderness and a high leukocyte count, indicating a severe infection, placement of a drain by interventional radiology (percutaneous cholecystostomy) may be the best next step, especially if the patient is considered high-risk for surgery 2, 5.
Key Considerations
- Early surgery (within 72 hours of diagnosis) is associated with better results and lower frequency of complications 4, 5, 6.
- Broad-spectrum antibiotics should be used in high-risk patients or those with severe infections 3, 4.
- Percutaneous cholecystostomy is associated with higher rates of postprocedural complications compared to laparoscopic cholecystectomy, but may be necessary for patients with exceptionally high perioperative risk 5.