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 is option 3, cholecystostomy, as it allows for immediate decompression of the infected gallbladder, drainage of purulent material, and clinical stabilization. This patient presents with clinical features consistent with acute cholecystitis complicated by empyema of the gallbladder, as evidenced by the severe abdominal pain, fever, right hypochondrial mass, mild jaundice, and leukocytosis. According to the 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis 1, percutaneous cholecystostomy can be considered in the treatment of ACC patients who are deemed unfit for surgery.

The guidelines also suggest that cholecystostomy is a valid option for patients with severe inflammation, as it reduces the risk of complications associated with immediate surgery, such as bile duct injury 1. While options 1 and 2 (open or urgent cholecystectomy) might eventually be necessary, immediate surgery in the setting of severe inflammation carries higher risks of complications. Conservative management with IV fluids and antibiotics alone (option 4) would be insufficient given the presence of a palpable mass suggesting a significantly distended, possibly gangrenous gallbladder.

Following cholecystostomy, the patient should receive broad-spectrum antibiotics covering enteric gram-negative organisms and anaerobes, and an interval cholecystectomy can be planned after the acute inflammation subsides, typically in 6-8 weeks. The 2019 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population also support the use of percutaneous cholecystostomy as a bridge to cholecystectomy in acutely ill (high-risk) elderly patients deemed unfit for surgery 1.

Key points to consider in the management of this patient include:

• The presence of a palpable mass suggesting a significantly distended, possibly gangrenous gallbladder
• The need for immediate decompression and drainage of the infected gallbladder
• The importance of broad-spectrum antibiotics in covering enteric gram-negative organisms and anaerobes
• The planning of an interval cholecystectomy after the acute inflammation subsides
• The consideration of percutaneous cholecystostomy as a bridge to cholecystectomy in high-risk patients.

From the Research

Management Options for Acute Cholecystitis

The patient's condition, with a history of gallstones, severe abdominal pain, fever, and a right hypochondrial mass, suggests acute cholecystitis. Considering the management options:

• Open cholecystectomy: This is a standard treatment for acute cholecystitis, but it poses significant risks for patients with advanced age and/or comorbid conditions 2.
• Urgent cholecystectomy: Similar to open cholecystectomy, urgent cholecystectomy may not be suitable for high-risk patients due to the risks associated with general anesthesia 3.
• Cholecystostomy: Percutaneous cholecystostomy (PC) is a viable option for patients who are high-risk surgical candidates. It provides significant clinical improvement in the short term and can be life-saving, especially in elderly patients or those with comorbid diseases 2, 3, 4, 5.
• Conservative management with IV fluids and antibiotics: While this approach may be considered for some patients, the presence of a right hypochondrial mass and leucocytosis suggests that more invasive management may be necessary.

Considerations for Cholecystostomy

Percutaneous cholecystostomy has been shown to be a safe and effective procedure for the treatment of acute cholecystitis in high-risk patients. It can serve as a bridge to surgery or as a definitive treatment option 3, 4, 5. The procedure has a low rate of complications and can provide significant clinical improvement in the short term.

Comparison of Management Options

A systematic review protocol has been proposed to compare the outcomes of critically ill patients with acute cholecystitis managed with percutaneous cholecystostomy versus cholecystectomy 6. However, based on the available evidence, percutaneous cholecystostomy appears to be a viable option for high-risk patients, with a low rate of mortality and subsequent cholecystectomy 5.