Case-Based Learning, June 2024

81-year-old female presented to the emergency department with complaints of generalized body aches and increasing illness over the past week. She reported fever, nausea, vomiting, and anorexia at home for the previous 8 days. She stated that because of the decreased appetite and nausea with vomiting, she has lost 15 pounds in the past week and a half. She also noted that she has a history of gallstones. On initial examination, she is afebrile. She does not meet SIRS criteria. Blood pressure is 116/73. She had tenderness in the right upper quadrant with palpation. She was administered hydromorphone 0.5 mg IV per pain protocol and morphine 4 mg IV per pain protocol. Workup included CBC, CMP, lactic acid, CRP, sed rate, urinalysis, and nasopharyngeal PCR 4 plex swab. She had both a limited right upper quadrant ultrasound and a CT angiography of the chest, abdomen, and pelvis during her evaluation in the emergency department.

White blood cell count was 16.7 with left shift. ESR 94. Sodium 131. Alkaline phosphatase 317. AST 92. A LT 415. Lactic acid 1.3. CRP 36.8. 4 plex swab is negative for COVID-19, influenza, and RSV. Urinalysis with small bilirubin, otherwise normal. Ultrasound demonstrated gallbladder distention with gallbladder wall thickening and cholelithiasis. There also appeared to be an oval shaped structure in the gallbladder lumen that probably represented tumefactive sludge. The overall appearance was concerning for cholecystitis although it is reported that a sonographic Murphy sign was absent per TeleRadia report. CT chest, abdomen, and pelvis demonstrated central lobular emphysema. Cholelithiasis was noted and the gallbladder wall thickness was measured as much as 9 mm. Findings were reported consistent with cholecystitis per TeleRadia report.

General surgery was consulted. At the time of the general surgeon’s examination, patient had received IV pain medication and was feeling better. Despite ultrasound and CT evidence of cholecystitis, patient’s presentation of abdominal pain with fever, nausea, and vomiting, and abnormal labs including leukocytosis and elevated liver function tests, the general surgeon determined that because she did not have a sonographic Murphy’s sign nor significant right upper quadrant pain with his examination after IV pain medication administration, this patient did not have evidence of acute cholecystitis and therefore recommended that a cholecystectomy was not in her best interest.

At emergency department change of shift, off going provider’s report to oncoming provider indicated that patient should be admitted to the hospitalist service for IV antibiotics as the general surgeon did not feel that the patient needed surgical intervention. After review of the patient’s workup and discussion with patient, including obtaining her history and performing an independent examination, the oncoming provider felt that the patient did indeed have signs and symptoms of cholecystitis and made arrangements for patient to transfer to a higher level of care for possible surgical management.

This case reflects challenges with multidisciplinary collaboration, in particular, when the treating emergency department physician disagrees with the recommendation from the consulted specialist. After change of shift, the oncoming provider spoke with the surgeon regarding his expressed opinion. The surgeon focused on the lack of pain at the time of his examination and the lack of sonographic Murphy’s sign as evidence that this patient did not have a diagnosis of acute cholecystitis.

Acute cholecystitis refers to a syndrome of right upper quadrant abdominal pain, fever, and leukocytosis associated with gallbladder inflammation. Characteristically, acute cholecystitis pain is prolonged more than 4-6 hours, steady, and severe with associated complaints including nausea, vomiting, and anorexia. For the majority of patients, acute cholecystitis is caused by gallstones while acalculous cholecystitis accounts for approximately 5-10% of cases. While a positive Murphy’s sign on physical examination supports the diagnosis, history, physical examination, and laboratory test findings are not sufficient alone to establish the diagnosis. The diagnosis of acute cholecystitis is established with a right upper quadrant ultrasound study that demonstrates gallbladder wall thickening or edema greater than 4-5 mm, pericholecystic fluid, or edema (double wall sign) particularly with gallstones present on the study or sonographic Murphy’s sign or failure of the gallbladder to fill during cholescintigraphy. Sensitivity and specificity for diagnosing acute cholecystitis on ultrasound are 88% and 80%, respectively. Sensitivity and specificity of ultrasound for detection of gallstones is 84% and 94%, respectively. The importance of diagnosing acute cholecystitis is that gangrenous cholecystitis as the most common complication of cholecystitis in up to 20% of cases particularly in older patients, patients with diabetes, or patients who delay seeking therapy. https://www.uptodate.com/contents/acute-calculous-cholecystitis-clinical-features-and-diagnosis?source=autocomplete&index=1~3&search=acute%20calculus (pgs 3-6)

Review of the algorithm for diagnosis of acute cholecystitis on UpToDate indicates that patients presenting with prolonged fever, Murphy’s sign, and/or leukocytosis in which acute cholecystitis is suspected should undergo urgent abdominal ultrasound. If there are positive ultrasound findings which include gallstones with gallbladder wall edema or ultrasound Murphy’s sign, the diagnosis of acute calculous cholecystitis is made. If there is gallbladder edema and Murphy’s sign without gallstones, cholescintigraphy is recommended and if positive, suggests acute acalculous cholecystitis. https://www.uptodate.com/contents/acute-calculous-cholecystitis-clinical-features-and-diagnosis?source=autocomplete&index=1~3&search=acute%20calculus (pg 17)

Cholecystectomy is the mainstay of treatment for acute calculus cholecystitis. Supportive care includes IV hydration, pain control with NSAIDS and opioids, correction of electrolyte abnormalities, and NPO status. Prophylactic antibiotic therapy with cefazolin before surgical incision for patients with mild-to-moderate acute calculus cholecystitis undergoing immediate cholecystectomy had fewer surgical site infections than those patients who did not. Antibiotics are required for all patients with complicated acute calculus cholecystitis (gallbladder gangrene, necrosis, rupture, or emphysema) and for uncomplicated patients who are frail, immunocompromised, or have diabetes. https://www.uptodate.com/contents/treatment-of-acute-calculous-cholecystitis?search=treatment%20of%20acute%20cholecystitis&source=search_result&selectedTitle=1%7E132&usage_type=default&display_rank=1 (pg 3)

Patients who are poor surgical candidates may benefit from initial non-operative management with antibiotics and gallbladder drainage procedure.

Initial nonoperative management with delayed cholecystectomy has traditionally been used as an alternative strategy to immediate cholecystectomy in older patients (> 65 years), however, data shows that outcomes for early laparoscopic cholecystectomy in octogenarians are comparable with those for younger patients. https://www.uptodate.com/contents/treatment-of-acute-calculous-cholecystitis?search=treatment%20of%20acute%20cholecystitis&source=search_result&selectedTitle=1%7E132&usage_type=default&display_rank=1 (pg 6-7)

Summary: 81-year-old female diagnosed with acute calculus cholecystitis. She did not have evidence of complicated acute cholecystitis and, therefore, did not require emergency cholecystectomy. She was a reasonable surgical candidate at a facility that could provide a higher level of post-operative care as needed. Data support early cholecystectomy for this patient despite her age > 65. She was transferred to an outside facility accepted by a general surgeon and hospitalist where she underwent cholecystectomy. She did experience a post-op bile leak and subsequently underwent an ERCP, biliary stent placement in the CBD, and IR drain placement of a large fluid collection in the gallbladder fossa during her hospitalization at the outside facility. She was discharged on post-op day #6 on Augmentin.