Acute Cholecystitis — SAQ 2

Stem

A 70-year-old man with type 2 diabetes mellitus presents with 48 hours of constant right upper quadrant pain, fever (39.0°C), and confusion. On examination he is tachycardic (120 beats/min), hypotensive (90/60 mmHg), and has a positive Murphy sign. CT shows a thickened gallbladder wall with gas in the wall and pericholecystic fluid. His bilirubin is 42 micromol/L and WBC is 22 x10^9/L.

Questions

a) What is the diagnosis, and what complication is suggested by the CT findings? (2 marks)

Diagnosis: Acute emphysematous cholecystitis (a severe form of acute cholecystitis). The CT finding of gas in the gallbladder wall is pathognomonic and indicates infection by gas-forming organisms (Clostridium, E. coli, Klebsiella). Diabetes and confusion are red flags for severity.

b) List four components of the initial resuscitation. (4 marks)

1. Nil by mouth (NBM) and nasogastric tube if vomiting/ileus.
2. Aggressive IV fluid resuscitation to correct hypotension and maintain urine output >0.5 mL/kg/h.
3. IV broad-spectrum antibiotics covering gram-negative bacilli, anaerobes, and gas-forming organisms (e.g., piperacillin-tazobactam or meropenem).
4. IV analgesia and early contact with theatre/anaesthetics for emergency surgery.

c) Why is this patient not suitable for immediate laparoscopic cholecystectomy, and what should be done instead? (2 marks)

He has septic shock and likely Tokyo Grade III disease (organ dysfunction: hypotension, confusion). He requires ICU resuscitation and organ support first. If he remains unstable or unfit for surgery, percutaneous cholecystostomy decompresses the septic source. Once stabilised, emergency/open cholecystectomy is often needed because of the high risk of perforation.

d) Name two indications for ERCP in this clinical scenario. (2 marks)

1. Ascending cholangitis if Charcot triad/Reynolds pentad is present.
2. Suspected common bile duct stone if bilirubin is rising, the CBD is dilated, or there is persistent jaundice/sepsis despite source control.