What is the management for a female patient with a history of cholelithiasis (gallstones) presenting with severe abdominal pain, fever, a right hypochondrial mass, mild jaundice, and leukocytosis?

From the Guidelines

The most appropriate management for this patient with severe abdominal pain, fever, right hypochondrial mass, mild jaundice, and leukocytosis with a history of gallstones is option 3: cholecystostomy. This patient is presenting with what appears to be acute cholecystitis complicated by possible empyema of the gallbladder or a gallbladder perforation, as evidenced by the palpable right hypochondrial mass. The presence of fever, leukocytosis, and jaundice suggests a severe inflammatory process with potential biliary obstruction. In such cases, immediate decompression of the gallbladder through percutaneous cholecystostomy is often the safest initial approach, as supported by the 2020 World Society of Emergency Surgery guidelines for the diagnosis and treatment of acute calculus cholecystitis 1. This procedure involves placing a drainage catheter into the gallbladder under imaging guidance to drain infected bile and pus, reducing inflammation and allowing the patient to stabilize. While urgent cholecystectomy might seem appropriate, the severity of inflammation and potential technical difficulties make immediate surgery risky, as noted in the 2019 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population 1. Conservative management with IV fluids and antibiotics alone would be insufficient given the severity of presentation and presence of a mass. After cholecystostomy and clinical improvement, a delayed cholecystectomy can be performed in a safer setting, typically after 6-8 weeks when inflammation has subsided, as recommended in the 2017 WSES guidelines for management of intra-abdominal infections 1. Key considerations in the management of acute cholecystitis include:

• Early diagnosis and intervention to prevent complications such as gallbladder perforation
• Assessment of the patient's risk for surgery and consideration of alternative treatments such as percutaneous cholecystostomy for high-risk patients
• The use of imaging studies such as ultrasound to guide diagnosis and treatment
• The importance of stabilizing the patient before proceeding with definitive surgical treatment. Overall, the management of acute cholecystitis requires a multidisciplinary approach and careful consideration of the patient's individual risk factors and clinical presentation.

From the Research

Management Options

The patient presents with severe abdominal pain, fever, and a right hypochondrial mass, indicating a possible case of acute cholecystitis. The management options include:

• Open cholecystectomy
• Urgent cholecystectomy
• Cholecystostomy
• Conservative management with IV fluids and antibiotics

Considerations for Each Option

The choice of management depends on the patient's condition and the severity of the disease.

• Open cholecystectomy and urgent cholecystectomy are surgical options that may be considered for patients who are suitable for surgery 2.
• Cholecystostomy, specifically percutaneous cholecystostomy, is a viable option for patients who are not suitable for surgery, such as those with advanced age or comorbid conditions 3, 4.
• Conservative management with IV fluids and antibiotics may be considered for patients with mild disease, but it is not a definitive treatment for acute cholecystitis.

Evidence for Cholecystostomy

Percutaneous cholecystostomy has been shown to be a safe and effective method for managing acute cholecystitis in high-risk patients 3, 4. A study found that almost 90% of patients with acute cholecystitis who were managed with percutaneous cholecystostomy alone recovered uneventfully without recurrent sepsis following tube removal 4. Another study suggested that percutaneous cholecystostomy may be overused, and patients may be burdened with the tube for extended periods 5.

Comparison of Management Options

A systematic review aimed to compare the outcomes of critically ill patients with acute cholecystitis managed with percutaneous cholecystostomy versus cholecystectomy 6. The review found that both interventions had their own advantages and disadvantages, and the choice of management depended on the patient's condition and the severity of the disease.

Antibiotic Use

The use of antibiotics in patients undergoing cholecystectomy for gallbladder disease is recommended for patients with acute cholecystitis, but not for low-risk patients undergoing elective laparoscopic cholecystectomy 2. The duration of antibiotic use should be limited to a maximum of four days, and perhaps a shorter duration in patients with severe disease.