Review Question - QID 103058

This patients presents with acute calculous cholecystitis. Definitive surgical management in the initial hospitalization should occur, with laparoscopic cholecystectomy being the operation of choice.

Acute calculus cholecystitis is caused by obstruction of the gallbladder neck by a gallstone. This obstruction leads to increased pressure and distention of the gallbladder. Over time, edema, release of inflammatory mediators, and bacterial extravasation into the parenchyma lead to inflammation. The management of acute cholecystitis involves IV hydration, analgesia for pain, nil per os, and surgical excision. Surgical management should occur during the initial hospitalization, and within 72 hours of symptomatic onset. If surgery isn't possible within this initial period, an interval cholecystectomy after antibiotic therapy is preferred.

Abraham et. al. discuss the different management strategies for acute cholecystitis. They conclude that laparoscopic cholecystectomy remains the surgery of choice, as it has an improved recovery time with a shorter length of hospital stay. For patients with symptomatic cholecystitis, who are too ill for surgery, decompression with percutaneous cholecystostomy is a viable strategy.

Yang et. al. reviewed the risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy. They found that prior abdominal surgery, concomitant diabetes, age greater than 65, male gender, and thickened gallbladder wall were independent risk factors for surgical conversion.

Figure A shows a right upper quadrant ultrasound demonstrating gallbladder thickening and gallstones, consistent with acute cholecystitis. Illustration A shows an ERCP with endoscopic stone retrieval after sphincterotomy.

Incorrect Answers
Answer 1: Interval cholecystectomy isn't recommended, as this patient is within the 72-hour window from symptom onset.
Answer 2: Open cholecystectomy is no required, as a laparoscopic approach is preferred.
Answer 4: a HIDA Scan is a diagnostic tool for diagnosis of cholelithiasis, this patient has sufficient diagnostic data to conclude acute cholecystitis.
Answer 5: ERCP is both diagnostic and therapeutic for choledocholithiasis (See Illustration A). There is no evidence of common duct stones in this patient, and if there is concern, an intraoperative cholangiogram is the procedure of choice.