An 80-year-old man admitted to the hospital with abdominal pain is diagnosed with acute cholecystitis. His abdominal ultrasound reveals a distended, thick-walled gallbladder with pericholecystic fluid and multiple gallstones. The common bile duct diameter is normal. The patient has a history of idiopathic pulmonary fibrosis and uses continuous oxygen at 4-5 L/min via nasal cannula. His other medical problems include hypertension, type 2 diabetes mellitus, and prior ischemic stroke with residual right-sided hemiparesis. He is started on intravenous fluids, analgesics, and piperacillin-tazobactam, but the next day he has increasing pain and confusion.
His temperature is 38.9 C (102 F), blood pressure is 90/45 mm Hg, and pulse is 116/min and regular. Pulse oximetry is 94% on 4 L oxygen. Abdominal examination is notable for right upper quadrant tenderness without rebound.
Laboratory results are as follows:

Which of the following is the most appropriate additional intervention in management of this patient?

Question

An 80-year-old man admitted to the hospital with abdominal pain is diagnosed with acute cholecystitis.  His abdominal ultrasound reveals a distended, thick-walled gallbladder with pericholecystic fluid and multiple gallstones.  The common bile duct diameter is normal.  The patient has a history of idiopathic pulmonary fibrosis and uses continuous oxygen at 4-5 L/min via nasal cannula.  His other medical problems include hypertension, type 2 diabetes mellitus, and prior ischemic stroke with residual right-sided hemiparesis.  He is started on intravenous fluids, analgesics, and piperacillin-tazobactam, but the next day he has increasing pain and confusion.
His temperature is 38.9 C (102 F), blood pressure is 90/45 mm Hg, and pulse is 116/min and regular.  Pulse oximetry is 94% on 4 L oxygen.  Abdominal examination is notable for right upper quadrant tenderness without rebound.
Laboratory results are as follows:

Which of the following is the most appropriate additional intervention in management of this patient?

Quizplus · Accepted Answer

This patient with acute cholecystitis is clinically deteriorating despite conservative treatment. The initial management of cholecystitis includes intravenous fluids, analgesics, and bowel rest. Empiric antibiotics with activity against gram-negative organisms and anaerobes (eg, piperacillin-tazobactam monotherapy, ceftriaxone plus metronidazole) should also be considered, especially in the setting of sepsis. Most low-risk surgical patients with cholecystitis should undergo early laparoscopic cholecystectomy as it is associated with reduced morbidity and mortality (Choice C). However, patients at high risk for surgery (such as this elderly patient with multiple comorbidities) who do not improve with conservative measures can benefit from a gallbladder drainage procedure such as percutaneous cholecystostomy. Once cholecystitis resolves, the risk of surgery can be reassessed; elective cholecystectomy should be performed in eligible patients to reduce the risk of recurrence. (Choice A) This patient is already on proper antibiotics with piperacillin-tazobactam; the addition of vancomycin and metronidazole is not indicated. (Choice B) Endoscopic retrograde cholangiopancreatography should be considered in patients with choledocholithiasis complicated by biliary pancreatitis or cholangitis. This patient has a normal-size common bile duct with normal alkaline phosphatase, bilirubin, and lipase levels, making these conditions unlikely. (Choice E) Dissolution therapy with ursodeoxycholic acid may be considered in patients with mild to moderate symptoms of uncomplicated gallstone disease who are not surgical candidates; however, it is not an appropriate treatment for acute cholecystitis. Educational objective: Most patients with cholecystitis should undergo early laparoscopic cholecystectomy as it is associated with reduced morbidity/mortality. Patients who are at high risk for surgery and fail to improve with conservative treatment (fluids, analgesics, empiric antibiotics) can benefit from percutaneous cholecystostomy. __________ References: Technique and indications of percutaneous cholecystostomy in the management of cholecystitis in 2014. (http://www.ncbi.nlm.nih.gov/pubmed/25168577)

An 80-Year-Old Man Admitted to the Hospital with Abdominal Pain