What is the management for a patient with cholelithiasis (gallstones) and leukocytosis (elevated white blood cell count) without gallbladder wall thickening or pericholecystic fluid?

From the Guidelines

Management for a patient with cholelithiasis and leukocytosis but without gallbladder wall thickening or pericholecystic fluid should focus on symptomatic treatment while planning for definitive management, with the goal of preventing recurrent biliary colic and potential complications like acute cholecystitis, pancreatitis, or cholangitis, as recommended by the 2020 World Society of Emergency Surgery guidelines 1.

Initial Treatment

Initial treatment includes:

• NPO status (nothing by mouth)
• Intravenous fluids for hydration
• Pain control with medications such as ketorolac 30mg IV every 6 hours or morphine 2-4mg IV every 4 hours as needed
• Antiemetics like ondansetron 4mg IV every 8 hours for nausea Antibiotics are generally not required in uncomplicated cholelithiasis without signs of cholecystitis, but the presence of leukocytosis warrants close monitoring for progression to infection.

Definitive Treatment

The definitive treatment is cholecystectomy, which can be performed laparoscopically, as it prevents recurrent biliary colic and potential complications like acute cholecystitis, pancreatitis, or cholangitis. According to the 2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population, laparoscopic cholecystectomy is safe and feasible in elderly patients, with a low complication rate and shortened hospital stay 1.

Follow-up and Monitoring

If the patient improves with conservative management, they can be discharged with oral pain medications (ibuprofen 600mg every 6 hours and/or acetaminophen 1000mg every 6 hours) and a low-fat diet while awaiting elective laparoscopic cholecystectomy, ideally within 4-6 weeks. If symptoms worsen or leukocytosis increases, the patient should be reassessed for development of acute cholecystitis, which would necessitate urgent surgical consultation and possible antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1g IV daily plus metronidazole 500mg IV every 8 hours.

From the Research

Management of Cholelithiasis with Leukocytosis

• The management of a patient with cholelithiasis and leukocytosis but no gallbladder wall thickening or pericholecystic fluid is crucial to prevent complications such as acute cholecystitis 2, 3, 4, 5.
• According to the studies, the presence of leukocytosis is a significant factor in determining the risk of acute cholecystitis, with a higher white blood cell count indicating a higher risk 6.
• The combination of patient age, sex, and white blood cell count can effectively stratify patients into risk groups for acute cholecystitis 6.
• For patients with a high risk of acute cholecystitis, early laparoscopic cholecystectomy is recommended, as it is associated with improved patient outcomes, including fewer composite postoperative complications and a shorter length of hospital stay 2, 5.
• In patients who are not eligible for early laparoscopic cholecystectomy, medical management comprising fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics may be necessary 2.
• Additionally, concomitant conditions such as choledocholithiasis, cholangitis, biliary pancreatitis, or systemic complications must be recognized and adequately treated 2.

Diagnostic Approach

• Ultrasonography is the gold standard for diagnosing cholelithiasis, and liver function tests and abdominal ultrasound are generally sufficient for diagnostic purposes 3, 4.
• The sonographic Murphy sign (SMS) can be used in combination with clinical parameters to effectively stratify patients into risk groups for acute cholecystitis 6.
• Hepatobiliary scintigraphy may be used as a diagnostic test when an ultrasound result does not provide a definitive diagnosis 5.

Treatment Options

• Laparoscopic cholecystectomy is the first-line therapy for acute cholecystitis, and early laparoscopic cholecystectomy is associated with improved patient outcomes 2, 5.
• Percutaneous cholecystostomy tube placement may be an effective therapy for patients with an exceptionally high perioperative risk, but it is associated with higher rates of postprocedural complications compared with laparoscopic cholecystectomy 5.
• Antibiotic therapy may be necessary in some cases, but prolonged antibiotic therapy after cholecystectomy seems inadvisable, except in severe cases and/or in the immuno-compromised patient 4.