In a 21‑year‑old male with sudden epigastric pain, ultrasound showing moderate fatty liver and multiple gallbladder calculi (or polyps) with normal wall thickness, and a leukocytosis of 36 × 10⁹/L, what is the most likely diagnosis and recommended acute management?

Acute Calculous Cholecystitis with Severe Leukocytosis

This 21-year-old male most likely has acute calculous cholecystitis requiring urgent laparoscopic cholecystectomy, and the markedly elevated WBC count of 36,000/μL raises concern for complicated cholecystitis (gangrenous, emphysematous, or perforated gallbladder) necessitating immediate surgical consultation and broad-spectrum antibiotics. 1, 2

Diagnostic Reasoning

Clinical Presentation Analysis

• Sudden epigastric pain in a young male with gallstones and extreme leukocytosis (36,000/μL) strongly suggests acute cholecystitis rather than chronic disease 1, 3
• The normal gallbladder wall thickness is somewhat atypical but does not exclude acute cholecystitis—wall thickness >3mm has only 38-41% sensitivity for acute disease 4
• Severe leukocytosis (36,000/μL is nearly 4× normal) indicates significant systemic inflammatory response and raises immediate concern for complicated cholecystitis with potential gangrenous changes, emphysema, or early perforation 2

Critical Ultrasound Findings to Reassess

The ultrasound report mentions "calculous or gallbladder polyp"—this distinction is crucial:

• If these are gallstones (calculi): Combined with severe leukocytosis and acute pain, this confirms acute calculous cholecystitis 1, 3
• If these are polyps: Polyps themselves don't cause acute inflammation or leukocytosis 1, 5
• Sonographic Murphy's sign must be documented—when positive with gallstones present, it has 92% positive predictive value for acute cholecystitis 3

Missing Critical Imaging Features

The ultrasound report is incomplete. You must specifically look for:

• Pericholecystic fluid (suggests acute inflammation) 1
• Intramural gas or intraluminal gas (indicates emphysematous cholecystitis) 2, 6
• Gallbladder wall irregularity or discontinuity (suggests perforation) 2
• Hyperechoic intraluminal material (may indicate hemorrhagic cholecystitis) 2
• Gallbladder distension (transverse diameter >5cm supports cholecystitis) 1

Immediate Management Algorithm

Step 1: Urgent Additional Imaging (Within Hours)

• Repeat focused ultrasound with optimized technique specifically assessing for complications of cholecystitis 1
• Consider CT abdomen with IV contrast if ultrasound equivocal—CT is superior for detecting emphysematous cholecystitis, hemorrhage, and perforation 1, 2, 6
• CT findings to look for: gas in gallbladder wall/lumen, wall enhancement abnormalities, extraluminal fluid collections 2

Step 2: Risk Stratification

Given the WBC of 36,000/μL, this patient likely has:

• Complicated cholecystitis until proven otherwise 2
• Risk factors present: The moderate fatty liver suggests metabolic syndrome, which increases surgical risk 1
• Young age (21) is protective, but the extreme leukocytosis overrides this 2

Step 3: Immediate Treatment Initiation

Antibiotics (start immediately, do not delay for imaging):

• Broad-spectrum coverage for complicated cholecystitis 2
• Extended course (4-7 days) will be needed if complicated features confirmed 2
• Must cover resistant organisms given severity 2

Surgical Consultation (urgent, same-day):

• Early laparoscopic cholecystectomy is preferred treatment for acute cholecystitis 1, 3
• With WBC 36,000/μL, surgery should occur within 24-48 hours maximum 1
• If complicated cholecystitis confirmed, urgent cholecystectomy (not delayed) is mandatory 2

Supportive Care:

• NPO status
• IV fluids for resuscitation
• NSAIDs for pain control (safe and effective for biliary pain) 7

Critical Pitfalls to Avoid

Pitfall #1: Dismissing Normal Wall Thickness

• Do not be falsely reassured by normal wall thickness—this can occur in early acute cholecystitis or in young patients with good tissue compliance 4
• Wall thickness >3mm has poor sensitivity (38-41%) for acute disease 4

Pitfall #2: Confusing Polyps with Stones

• Polyps are nonshadowing, nonmobile, and do not cause acute inflammation 5
• If truly polyps (not stones), the acute presentation with WBC 36,000/μL indicates a different diagnosis entirely
• Demand clarification from radiology or repeat imaging 1

Pitfall #3: Underestimating Disease Severity

• WBC 36,000/μL is not typical uncomplicated cholecystitis—this level suggests complicated disease with potential gangrene or perforation 2
• Complicated cholecystitis carries significantly higher morbidity and mortality 2
• Delayed recognition leads to sepsis, perforation, and death 2, 8

Pitfall #4: Delaying Surgery

• Early cholecystectomy (within 72 hours of symptom onset) results in shorter recovery and hospitalization 3
• With this degree of leukocytosis, waiting risks progression to perforation 2
• If source control is complete with cholecystectomy, no postoperative antibiotics needed for uncomplicated cases 3

Addressing the Fatty Liver Finding

The moderate fatty liver is relevant but secondary:

• Nonalcoholic fatty liver disease is a risk factor for gallstone formation 7
• Does not change acute management of cholecystitis
• Requires metabolic workup and lifestyle modification after acute episode resolves 7

If Imaging Confirms Complicated Features

Emphysematous cholecystitis (gas in wall/lumen):

• Requires immediate surgery 2, 6
• Associated with gas-forming organisms 8
• High mortality if delayed 2

Gallbladder perforation (wall discontinuity, extraluminal fluid):

• Emergent surgery required 2
• Broader antibiotic coverage 2

Gangrenous cholecystitis:

• May not have specific imaging findings early 2
• Suspected with extreme leukocytosis and severe clinical presentation 2