Acute Cholecystitis on Dual Antiplatelet Therapy After Recent Coronary Stenting
A 64-year-old man underwent percutaneous coronary intervention with a drug-eluting stent in the left anterior descending artery 10 weeks ago for unstable angina. He takes aspirin 100 mg daily and ticagrelor 90 mg twice daily. He presents with 2 days of right upper quadrant pain, fever 38.6°C, and vomiting. Examination shows a positive Murphy sign. White cell count is 15,200/µL, CRP 180 mg/L, bilirubin normal, alkaline phosphatase 140 U/L. Ultrasound shows a distended gallbladder with wall thickness 5 mm, pericholecystic fluid, and no common bile duct dilatation. The surgical resident wants immediate laparoscopic cholecystectomy. Cardiology advises continuing dual antiplatelet therapy because the stent is recent. The patient is anxious and asks whether surgery can wait.
1. How would you risk-stratify and manage this patient?
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This is moderate acute cholecystitis by Tokyo criteria (fever, leukocytosis, wall thickening, pericholecystic fluid). Immediate laparoscopic cholecystectomy on dual antiplatelet therapy carries a high bleeding risk, while the stent is only 10 weeks old and premature cessation of ticagrelor risks stent thrombosis. Because there is no sepsis or perforation, initial conservative management is reasonable: nil by mouth, IV fluids, analgesia, and IV antibiotics, with close surgical review. If pain, fever, or white cell count worsen, or if the gallbladder is grossly distended, percutaneous cholecystostomy is safer than immediate surgery. Cardiology should be involved in any antiplatelet decision. Do not stop DAPT unilaterally. Interval cholecystectomy can be planned after the stent matures, usually after 6 months, depending on cardiology advice.
2. What antiplatelet strategy would you recommend if surgery becomes unavoidable within 48 hours?
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If surgery becomes unavoidable within 48 hours, continue aspirin and involve cardiology urgently. Stopping ticagrelor for 3–5 days reduces bleeding but increases stent thrombosis risk; in a recent drug-eluting stent this is a major hazard. For truly urgent surgery, many centers proceed on dual therapy with meticulous hemostasis, avoiding blind dissection, and reserving platelet transfusion for uncontrolled bleeding rather than routine prophylaxis. If the procedure can be done percutaneously under local anesthesia (cholecystostomy), that is preferred. The choice should be documented as a shared decision with cardiology and the patient, balancing bleeding against myocardial infarction and stent thrombosis.
3. How do you obtain informed consent in this situation?
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Informed consent must explain the diagnosis, the option of conservative treatment with drainage, and the option of surgery. For surgery, discuss bleeding requiring transfusion, conversion to open, bile duct injury, infection, and the risk of stent thrombosis if antiplatelet therapy is interrupted. For conservative care, discuss failure, recurrent cholecystitis, and the need for a drain. The patient's anxiety is relevant; explore his concerns and confirm he understands that waiting is not risk-free. Document capacity, the discussion with cardiology, and the agreed plan. If he cannot decide, identify a proxy and act in his best interests.