What is the plan for a patient with calculous cholecystitis (inflammation of the gallbladder due to gallstones) shown on Ultrasound (US) with signs of pancreatitis, but normal lipase levels?

From the Guidelines

For calculous cholecystitis with ultrasound signs of pancreatitis but normal lipase, I recommend prompt surgical consultation for cholecystectomy after initial medical management. Begin with NPO status, IV fluids (normal saline at 100-125 mL/hr), and pain control using hydromorphone 0.5-1 mg IV every 4-6 hours as needed or morphine 2-4 mg IV every 4 hours. Start antibiotic therapy with piperacillin-tazobactam 3.375 g IV every 6 hours (or ceftriaxone 1 g IV daily plus metronidazole 500 mg IV every 8 hours if penicillin allergic) 1. Despite normal lipase, the ultrasound findings suggest possible biliary pancreatitis, which can occur with gallstone disease. Monitor vital signs, pain levels, and repeat lipase and liver function tests in 12-24 hours. The discrepancy between imaging and laboratory findings may reflect early pancreatitis before enzyme elevation or localized inflammation near the pancreas without true pancreatitis.

Key Considerations

• Surgical timing depends on clinical stability, with early cholecystectomy (within 24-72 hours) preferred when feasible to prevent recurrence and complications like cholangitis or worsening pancreatitis 1.
• Abdominal ultrasound is the preferred initial imaging technique for patients suspected of having acute cholecystitis, due to its lower costs, better availability, lack of invasiveness, and good accuracy for stones 1.
• The evaluation of the risk for patients with acute cholecystitis should include mortality rate for conservative and surgical therapeutic options, rate of gallstone-related disease relapse, age-related life expectancy, and patient frailty evaluation by the use of frailty scores 1.
• Laparoscopic approach should always be attempted at first, except in case of absolute anesthetic contraindications and septic shock, and early laparoscopic cholecystectomy should be performed as soon as possible but can be performed up to 10 days of onset of symptoms 1.

Management

• General supportive care, consisting of vigorous fluid resuscitation, supplemental oxygen as required, correction of electrolyte and metabolic abnormalities, and pain control, must be provided to all patients 1.
• Nutritional support should be provided in those patients likely to remain “nothing by mouth” for more than 7 days, with nasojejunal tube feeding preferred over total parenteral nutrition 1.

From the Research

Diagnosis and Management of Calculous Cholecystitis with Pancreatitis

• The patient presents with calculous cholecystitis and signs of pancreatitis on ultrasound, but with normal lipase levels 2, 3.
• The diagnosis of acute cholecystitis can be made using ultrasonography, which has a sensitivity of approximately 81% and a specificity of approximately 83% 3, 4.
• In cases where the ultrasound result is not definitive, hepatobiliary scintigraphy can be used as the gold standard diagnostic test 3.
• The management of acute calculous cholecystitis typically involves early laparoscopic cholecystectomy, which is associated with improved patient outcomes, including fewer composite postoperative complications and a shorter length of hospital stay 3, 5.

Considerations for Patients with Pancreatitis

• The presence of pancreatitis complicates the management of calculous cholecystitis, and the patient's normal lipase levels do not rule out the diagnosis of pancreatitis 6.
• The Revised Atlanta Classification (RAC) criteria can be used for the diagnosis of acute biliary pancreatitis, and endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy are primary treatments 5.
• Minimally invasive approaches, such as endoscopic drainage, may be preferred for managing complications like infected pancreatic necrosis 5.

Treatment Options

• Early laparoscopic cholecystectomy is the recommended treatment for acute calculous cholecystitis, but high-risk patients may benefit from alternative treatments like biliary drainage 3, 5.
• Conservative management, including strict conservative therapy, may be successful in high-risk patients, such as the elderly, and can avoid the complications of surgery 6.
• The choice of treatment should be individualized based on the patient's risk factors, comorbidities, and overall health status 3, 5.