Middle-aged Woman With Abdominal Pain
A 50-year-old woman is hospitalized after she presents with abdominal pain. The pain is episodic and is located in the epigastric area and toward the right upper quadrant (RUQ). It awakened her from sleep, and there was an initial bout of nausea and vomiting at the onset. She has had similar, milder episodes during the previous months, but the current attack is far more severe and persistent.
She is otherwise healthy and has no history of diabetes. Her only long-term medication is a statin for mild hypercholesterolemia.
The patient is in moderate distress from the abdominal pain. Temperature is 38.8°C (102°F); heart rate, 100 beats per minute; and blood pressure, 118/72 mm Hg. Body mass index is 28 kg/m2. She is anicteric; heart and lungs are normal. Abdominal guarding is noted; bowel sounds are diminished but present. There is exquisite tenderness to palpation of the epigastrium and RUQ. No abdominal masses are detected.
The hemogram reveals a white blood cell (WBC) count of 14,500/µL with a left shift. Metabolic profile is within normal limits, including a normal bilirubin level. Serum amylase level is normal.
Which of the following statements about the management of this patient’s condition is correct?
A. Abdominal ultrasonography is less useful than scintigraphy in diagnosis.
B. Antibiotics are not indicated in this patient.
C. Early laparoscopic cholecystectomy is the recommended procedure for this patient.
D. The history suggestive of prior attacks is atypical for most patients with acute cholecystitis.
(Answer on next page)
Correct Answer: C
This patient exhibits findings that are typical of, or considered classic for, acute cholecystitis. The history further suggests acute calculous cholecystitis with previous episodes of reversible stone impaction that finally eventuated in prolonged impaction with subsequent inflammation (and possible infection) of the gallbladder. Thus, her findings are very typical, and choice D is not correct.
This syndrome is an extremely common and important condition in the United States and needs to be recognized by essentially any physician. The issues then become, as the vignette questions relate, what are the appropriate ways to:
•Make the diagnosis definitively.
•Adjudicate the severity potential of the case.
•Address timing and specifics of therapy.
Diagnostic criteria have been most firmly defined by the so-called Tokyo guidelines.1 These require the presence of one local sign or symptom (pain or tenderness in the RUQ, mass in the RUQ), one systemic sign (fever, leukocytosis, elevated C-reactive protein level), and a confirmatory finding with an imaging test.
Which imaging test is the issue of choice A. Many studies have demonstrated and compared the efficacy of scintigraphy and/or ultrasonography in acute cholecystitis. In summary, scintigraphy indeed has a higher specificity and accuracy than ultrasonography,2 but the ease, availability, and convenience of abdominal ultrasonography has resulted in its being the favored, more common initial imaging study with scintigraphy being reserved for the minority of unclear cases. Thus, choice A is not correct.3
ASSESSMENT OF SEVERITY
The severity of acute cholecystitis has also been categorized by the Tokyo guidelines into mild (grade I), moderate (grade II), and severe (grade III). The reader is referred to the reference,1,3 but in summary this patient has mild (grade I) disease by clinical and laboratory criteria. This subsequently helps formulate therapy considerations.
Treatment for calculous cholecystitis is cholecystectomy. The issues are timing and method—early versus late, laparoscopic versus open.4 Meta-analysis has demonstrated early surgery is superior with regard to persistence or recurrence of symptoms and hospital stay, with no difference in mortality.4 This patient has mild, grade I disease, and current guidelines would be for prompt laparoscopic cholecystectomy to be performed. Thus, choice C is correct.
The criteria for initiation of antibiotics when infection is suspected are3:
•WBC count of higher than 12,500/µL.
•Fever (temperature of higher than 38.5°C [101.3°F]).
•Radiographic findings of air in the gallbladder.
This patient had two of these findings, so antibiotics are indicated and choice B is incorrect.
OUTCOME OF THIS CASE
An abdominal ultrasound scan confirmed the presence of gallstones and thickening of the gallbladder wall (Figure). Antibiotic therapy with a quinolone and metronidazole was initiated, and an uncomplicated laparoscopic cholecystectomy was performed on day 3. The patient did well and has been symptom free.
1. Yamashita Y, Takada T, Kawarada Y, et al. Surgical treatment of patients with acute cholecystitis: Tokyo guidelines. J Hepatobiliary Pancreat Surg. 2007;14:91-97.
2. Chatziioannou SN, Moore WH, Ford PV, Dhekne RD. Hepatobiliary scintigraphy is superior to abdominal ultrasonography in suspected acute cholecystitis. Surgery.2000;127:609-613.
3. Strasberg SM. Acute calculous cholecystitis. N Engl J Med. 2008;358:2804-2811.
4. Sidiqui T, MacDonald A, Chong PS, Jenkins JT. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis of randomized clinical trials. Am J Surg. 2008;195:400-407.