What is the appropriate management for a patient with a hydropic gallbladder?

Management of Hydropic Gallbladder

A hydropic gallbladder requires cholecystectomy in symptomatic patients, ideally performed laparoscopically within 2-4 weeks of diagnosis to prevent complications including perforation, gangrene, and sepsis. 1, 2

Initial Diagnostic Confirmation

• Obtain abdominal ultrasound to confirm a markedly distended gallbladder without calculi or congenital malformation, with normal biliary ducts 3
• Order liver function tests including direct and indirect bilirubin, AST, ALT, ALP, GGT, and albumin to assess for biliary obstruction or cholangitis 1
• Check inflammatory markers (CRP, PCT, lactate) in patients appearing systemically ill to evaluate severity of acute inflammation and sepsis 1
• Consider CT abdomen if ultrasound findings are equivocal or if complications such as perforation, abscess formation, or bile peritonitis are suspected 1

Risk Stratification and Timing

Symptomatic patients with hydropic gallbladder require urgent surgical referral regardless of whether stones are present, as the distended gallbladder is at high risk for complications 2, 4

• Patients with fever, peritoneal signs, or hemodynamic instability require immediate surgical consultation for potential emergent cholecystectomy 2
• Patients with right upper quadrant pain, nausea, vomiting, or palpable mass should undergo laparoscopic cholecystectomy within 24-72 hours once stabilized 2
• Asymptomatic hydropic gallbladder discovered incidentally still warrants elective cholecystectomy given the unpredictable natural history and risk of acute decompensation 1

Surgical Management Algorithm

Laparoscopic cholecystectomy is the definitive treatment and should be performed by a surgeon experienced in this technique 1, 2

• Ensure the surgeon is appropriately qualified in laparoscopic techniques, as bile duct injury rates are higher with inexperienced operators 1
• Open cholecystectomy is acceptable if laparoscopic expertise is unavailable or if intraoperative findings necessitate conversion 1
• Intraoperative cholangiography should be considered given the distorted anatomy from gallbladder distention, which increases bile duct injury risk 1

Antibiotic Coverage

Initiate broad-spectrum antibiotics preoperatively if there are signs of acute cholecystitis, cholangitis, or systemic infection 1

• Use 4th-generation cephalosporins for patients with signs of local or systemic sepsis 1
• Escalate to piperacillin/tazobactam, imipenem/cilastatin, or meropenem if biliary peritonitis, biloma, or severe sepsis is present 1
• Adjust antibiotics based on culture results once available 1

Management of Complications

If bile peritonitis is identified intraoperatively or on imaging, urgent abdominal lavage and drainage are required as the first step to achieve source control 1

• Place percutaneous drains for any fluid collections identified on CT imaging prior to definitive surgery 1
• Perform ERCP with sphincterotomy and stent placement if bile leak is suspected or confirmed, particularly if surgery must be delayed 1
• Refer immediately to a hepatopancreatobiliary center if major bile duct injury is identified during or after surgery 1, 5

Special Populations

Pediatric patients with acute hydrops may be managed conservatively with observation if systemically well, as spontaneous resolution can occur 3

• Serial ultrasounds every 24-48 hours to monitor for resolution or progression 3
• Proceed to cholecystectomy if symptoms worsen, gallbladder enlarges, or no improvement occurs within 7-10 days 3

Patients at prohibitive surgical risk (ASA class 4-5, severe cardiopulmonary disease, limited life expectancy) may be managed with percutaneous cholecystostomy tube placement as a temporizing measure 1

• This is not definitive treatment and carries risk of tube dislodgement, bile leak, and recurrent cholecystitis 6
• Reassess surgical candidacy once acute inflammation resolves, as delayed cholecystectomy may become feasible 1

Critical Pitfalls to Avoid

Do not adopt a "wait and see" approach in symptomatic patients, as hydropic gallbladder can rapidly progress to perforation, gangrene, or septic shock 7, 4, 8

Do not mistake hydropic gallbladder for other acute abdominal conditions such as appendicitis, as the distended gallbladder can extend to atypical locations including the right lower quadrant or pelvis 4, 8

Do not delay imaging if clinical suspicion exists, even if presentation is atypical, as early diagnosis prevents life-threatening complications 7, 4, 8

Do not assume acalculous disease is benign, as both calculous and acalculous hydropic gallbladders require the same aggressive surgical management 3, 8