A 45 year old female presents with symptoms of acute Cholecystitis. On USG there is a solitary gallstone of size 1.5 cm. Symptoms are controlled with medical management. Which of the following is the next most appropriate step in the management of this patient?
Management of Acute cholecystitis IV fluids, analgesics and antibiotics are given initially in a pt. presenting with acute cholecystitis. Cholecystectomy is the definitive treatment. The timing of cholecystectomy was a matter of debate in the past. Early cholecystectomy performed within 2 to 3 days of presentation is preferred over interval or delayed cholecystectomy that is performed 6 to 10 weeks after initial medical therapy. Several studies have shown that unless the patient is unfit for surgery, early cholecystectomy is done as it provides a definitive treatment in one hospital admission & quicker recovery time. Laparoscopic cholecystectomy is the preferred approach Conversion to open cholecystectomy is made if the inflammation prevents adequate visualization of impoant structures. The conversion rate to open cholecystectomy is higher in the settings of acute cholecystitis than with chronic cholecystitis. If a patient presents late, after 3 to 5 days of illness, or in unfit for surgery, he is treated with analgesics, antibiotics and laparoscopic cholecystectomy is scheduled for approximately 2 months later. But if the patient fails to respond to initial medical therapy he would then need a surgical intervention. Laparoscopic cholecystectomy could be attempted, but the conversion rate is high and some prefer to go directly for an open cholecystectomy. For those unfit for surgery, a percutaneous cholecystostomy or an open cholecystostomy under local analgesia can be performed. Acute cholecystitis may progress to complications like empyema of the gall bladder, emphysematous cholecystitis, or perforation of the gall bladder despite antibiotic therapy. Emergency cholecystectomy is the procedure of choice for these complications, if the patient can safely withstand an anesthetic. Laparoscopic cholecystectomy could be attempted, but the conversion rate to open procedure is high and some prefer to go directly for an open cholecystectomy. Occasionally, the inflammatory process obscures the structures in the triangle of Calot, making dissection and ligation of the cystic duct unsafe. In these patients, paial cholecystectomy, cauterization of the remaining gall bladder mucosa, and drainage avoid injury to the CBD. If a patient is too unstable to tolerate a surgery, percutaneous cholecystostomy (or an open cholecystostomy) under local analgesia can be performed to drain the gall bladder. Delayed cholecystectomy can then be done once the inflammation has resolved. Ref : Schwaz 9/e p1148
Regular follow up
IV Antibiotics
Laparoscopy cholecystectomy immediately
Open cholecystectomy immediately
G.I.T