What is the appropriate management for a patient presenting with epigastric pain, elevated liver enzymes, and symptoms suggestive of acute cholecystitis?

Management of Dengue with Warning Signs and Suspected Acute Cholecystitis

Proceed immediately with right upper quadrant ultrasound to confirm or exclude acute cholecystitis, while continuing supportive care for dengue with warning signs, and prepare for early laparoscopic cholecystectomy within 24-72 hours if cholecystitis is confirmed. 1, 2

Immediate Diagnostic Workup

• Obtain right upper quadrant ultrasound urgently to evaluate for acute cholecystitis, looking specifically for pericholecystic fluid, distended gallbladder (>5 cm), edematous gallbladder wall (>5mm), gallstones, and ultrasonographic Murphy's sign 1, 3
• Ultrasound has 81% sensitivity and 83% specificity for acute cholecystitis diagnosis 2
• If ultrasound is inconclusive, proceed with hepatobiliary iminodiacetic acid (HIDA) scan which has 80-90% sensitivity 3
• Obtain complete blood count, liver function tests (already elevated: AST 69.6, ALT 80.70), and inflammatory markers to assess severity 1

Initial Medical Management

Continue aggressive fluid resuscitation given dengue with warning signs and potential acute cholecystitis, monitoring for fluid overload 3

For pain management:

• Continue HNBB (hyoscine-N-butylbromide) 10 mg IV as ordered for visceral pain 3
• Add acetaminophen for multimodal analgesia (avoid NSAIDs given dengue and thrombocytopenia risk) 3
• Continue omeprazole 40 mg IV OD as ordered 1

Antibiotic therapy if cholecystitis confirmed:

• Start piperacillin/tazobactam 4g/0.5g IV every 6 hours as first-line empiric therapy for acute cholecystitis 1, 3, 4
• This provides broad-spectrum coverage including typical biliary pathogens and Pseudomonas 4
• Alternative: amoxicillin/clavulanate 2g/0.2g IV every 8 hours for uncomplicated cases 1
• Administer antibiotics within first hour if sepsis is suspected 3, 4

Definitive Surgical Management

Early laparoscopic cholecystectomy is the treatment of choice if acute cholecystitis is confirmed 5, 1, 2

Timing considerations:

• Perform surgery within 7-10 days of symptom onset, ideally within 24-72 hours after diagnosis and initial stabilization 5, 1, 2
• Early cholecystectomy (within 1-3 days) versus delayed (>3 days) shows: fewer postoperative complications (11.8% vs 34.4%), shorter hospital stay (5.4 vs 10.0 days), and lower costs 2
• Laparoscopic approach is associated with lower morbidity (0.9%) and mortality compared to open cholecystectomy (6.2% morbidity) 5

Do not delay surgery based solely on dengue diagnosis if patient is hemodynamically stable and platelet count permits safe surgery 3, 2

Predictors of Conservative Management Failure

High-risk features requiring urgent surgical intervention:

• Tachycardia >100 bpm (OR 5.6 for failure at 24 hours) 3
• Distended gallbladder >5 cm transverse diameter (OR 8.5) 3
• Leukocytosis >15,000 cells/mm³ (OR 13.7 for failure at 48 hours) 3
• Persistent fever despite antibiotics 3
• Signs of gallbladder perforation, gangrene, or emphysematous cholecystitis require emergency operation 5, 6

Postoperative Antibiotic Duration

If cholecystectomy performed with adequate source control:

• No postoperative antibiotics needed for uncomplicated cholecystitis in immunocompetent patients 5, 1
• Continue antibiotics for 4 days postoperatively if patient is critically ill or has complicated cholecystitis 1, 4
• Obtain intraoperative bile cultures to guide targeted therapy if needed 1, 4

Alternative Management for High-Risk Patients

If patient is temporarily unfit for surgery due to dengue complications (severe thrombocytopenia, shock, bleeding):

• Percutaneous cholecystostomy is safe and effective as bridge to surgery 5, 7
• However, cholecystostomy has higher complication rates (65%) compared to laparoscopic cholecystectomy (12%) 2
• Plan delayed laparoscopic cholecystectomy at least 6 weeks after cholecystostomy placement once dengue resolves 7

Critical Pitfalls to Avoid

• Do not delay ultrasound imaging - positive Murphy's sign with RUQ tenderness and elevated liver enzymes strongly suggests cholecystitis requiring urgent confirmation 5, 1
• Do not use NSAIDs for pain control given dengue and risk of bleeding complications 3
• Do not delay source control for prolonged antibiotic courses - antibiotics alone cannot sterilize an obstructed, infected gallbladder 4
• Do not assume elevated transaminases are solely from dengue - acute cholecystitis can cause significant hepatic enzyme elevation 5
• Monitor platelet count closely before any invasive procedure given dengue diagnosis 2