A 71-year-old male with past medical history of hypertension, hyperlipidemia, congestive heart failure with 20% ejection fraction, and chronic obstructive pulmonary disease on 3 L home oxygen presents to the emergency department from his nursing home with complaints of: 5 days of fever, nausea, and right upper quadrant abdominal pain. His vital signs are as follows:
He undergoes an ultrasound that shows cholelithiasis, gallbladder wall thickening with pericholecystic fluid, and a positive sonographic Murphy sign, consistent with a diagnosis of acute calculous cholecystitis.
What is the most appropriate management?
A. IV antibiotics aloneCorrect Answer: E
Acute calculous cholecystitis is inflammation of the gallbladder in the presence of gallstones and obstruction of the cystic duct. Typical management involves initiation of antibiotic therapy and surgical cholecystectomy if the patient is an appropriate candidate. The patient presented above is a high surgical risk candidate given his multiple comorbidities and poor baseline functional status. Therefore, it would not be advisable to proceed with operative intervention at this time including laparoscopic or open cholecystectomy. In the setting of sepsis and presentation >72 hours after onset of symptoms it is unlikely that intravenous antibiotics alone will lead to resolution, although initiation of antibiotic therapy within 6 hours is recommended, or within 1 hour in patients presenting in septic shock. Endoscopic retrograde cholangiopancreatography is a procedure performed for a variety of reasons, including common bile duct obstruction in choledocholithiasis or cholangitis, but it is not typically used to address cystic duct obstruction in the setting of acute cholecystitis. The most appropriate management of this patient would include placement of a percutaneous cholecystostomy tube under ultrasound guidance. This allows for decompression of the gallbladder and can be done under local anesthesia and thus places minimal physiologic strain on this unstable and comorbid patient. The success rate for percutaneous cholecystostomy tube for the treatment of calculous cholecystitis is over 90% with a complication rate (most importantly bleeding and bile leakage) of less than 10%. Typically, these tubes remain in place for a minimum of 4 to 6 weeks, at which time further evaluation is performed with cholangiography, and a decision can be made about the need for elective cholecystectomy.
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