A 44-year-old woman presents to the emergency department with 18 hours of worsening right upper quadrant abdominal pain. The pain began several hours after eating a large meal and has been associated with nausea and vomiting. Her medical history is significant for obesity, hyperlipidemia, and type 2 diabetes mellitus. Medications include metformin and atorvastatin. Temperature is 38.2°C (100.8°F), blood pressure is 126/78 mm Hg, pulse is 104/min, and respiratory rate is 18/min. Physical examination reveals right upper quadrant tenderness to palpation and inspiratory arrest during palpation beneath the right costal margin. Laboratory studies show a leukocyte count of 14,500/mm³, AST of 42 U/L, ALT of 38 U/L, alkaline phosphatase of 115 U/L, and total bilirubin of 0.9 mg/dL. Right upper quadrant ultrasonography demonstrates gallstones, gallbladder wall thickening, and pericholecystic fluid.
Which of the following is the most appropriate next step in management?
The correct answer is:
C: Intravenous antibiotics and early laparoscopic cholecystectomy.
This patient has acute cholecystitis, as evidenced by prolonged right upper quadrant abdominal pain, fever, leukocytosis, a positive Murphy sign, and ultrasonographic findings of gallbladder inflammation. Initial treatment includes intravenous fluids, analgesia, and antibiotics, followed by early laparoscopic cholecystectomy during the same hospitalization. Early surgery reduces recurrent symptoms and complications.
Answer choice A: Elective cholecystectomy in 6 months, is incorrect.
Students may recognize that gallstones ultimately require surgical treatment. However, delaying surgery in a patient with active acute cholecystitis increases the risk of recurrent attacks and complications.
Answer choice B: Endoscopic retrograde cholangiopancreatography, is incorrect.
ERCP is appropriate for choledocholithiasis or cholangitis. This patient has normal bilirubin levels and no evidence of common bile duct obstruction.
Answer choice D: Observation and discharge home, is incorrect.
The presence of fever, leukocytosis, and imaging-confirmed inflammation requires inpatient treatment rather than observation alone.
Answer choice E: Oral proton pump inhibitor therapy, is incorrect.
Acid suppression may benefit peptic ulcer disease or GERD but does not address gallbladder inflammation.
Key Learning Point
Acute cholecystitis is treated with supportive care, antibiotics, and early laparoscopic cholecystectomy during the same hospitalization.
