On this page
Study tools
Write your answer
Saved on this device. No marking — you are the marker.
Stem
A 50-year-old woman with type 2 diabetes presents with 36 hours of constant right upper quadrant pain radiating to the right shoulder tip, fever (38.3°C), nausea, and vomiting. Examination: tender RUQ with positive Murphy sign. WBC 14.5 ×10⁹/L, CRP 85 mg/L, bilirubin normal, amylase normal. Ultrasound: 2 cm stone at the gallbladder neck, wall 5 mm, pericholecystic fluid, sonographic Murphy positive.
Questions
a) Diagnosis, mechanism, and Tokyo severity grade with justification. (3 marks)
Acute calculous cholecystitis. A gallstone impacts the cystic duct (here at the neck/Hartmann region) → gallbladder outflow obstruction → raised intraluminal pressure, mucosal ischaemia, chemical inflammation from concentrated bile, then secondary bacterial infection (commonly Enterobacterales). About 90% of acute cholecystitis is calculous.
Tokyo Guidelines Grade I (mild) is the best fit: local inflammatory disease with systemic inflammatory signs but no organ dysfunction (no shock, respiratory failure, AKI, coagulopathy, or CNS depression described). Diabetes does not automatically equal Grade III, but it raises risk of gangrene/emphysematous progression — mention this as a clinical caveat.
b) Write the first 1-hour management bundle with drug, dose, and route. (4 marks)
- NBM; large-bore IV access; crystalloid resuscitation (e.g. Hartmann's 500–1000 mL then reassess).
- Analgesia: paracetamol 1 g IV/PO every 6 h + opioid e.g. morphine 5–10 mg IV titrated (or NSAID such as diclofenac 75 mg IM if no contraindication — renal/GI/CV risk).
- Antibiotics: co-amoxiclav 1.2 g IV every 8 h or cefuroxime 1.5 g IV every 8 h + metronidazole 500 mg IV every 8 h (gram-negative rods + anaerobes). Escalate to piperacillin-tazobactam 4.5 g IV every 8 h if septic/severe.
- Blood cultures if febrile/septic; VTE risk assessment; glucose control; surgical admission for early cholecystectomy pathway.
c) Definitive treatment, timing evidence, and the critical view of safety. (5 marks)
Early laparoscopic cholecystectomy on the index admission, ideally within 72 hours of symptom onset (TG18 / NICE-aligned). Compared with planned delayed/interval surgery after “cooling off,” early surgery reduces total hospital stay and readmissions with recurrent biliary disease without a consistent increase in bile-duct injury in modern series.
Critical view of safety (Strasberg): (1) hepatocystic triangle cleared of fat/fibrous tissue; (2) lower one-third of gallbladder dissected off the liver cystic plate; (3) only two structures enter the gallbladder — cystic duct and cystic artery — documented before clipping. If CVS cannot be achieved safely: bail-out with subtotal cholecystectomy, conversion to open, or drainage/cholecystostomy rather than risking a duct injury.
d) Complications of disease and of surgery; when to use percutaneous cholecystostomy. (3 marks)
Disease: gangrene, perforation (localised abscess or generalised peritonitis), empyema, emphysematous cholecystitis, sepsis, Mirizzi syndrome.
Surgery: bile duct injury (~0.3–0.5%), bile leak (cystic stump/duct of Luschka), bleeding, conversion, retained CBD stone, port-site infection.
Cholecystostomy: Tokyo Grade III (organ dysfunction) or prohibitive operative risk / many ICU acalculous cases — bridge source control, then reassess fitness for interval cholecystectomy.