Acute cholecystitis in a patient who is fully anticoagulated
A 68-year-old retired teacher with permanent atrial fibrillation on warfarin (target INR 2.5) presents at 09:00 with 30 hours of right upper quadrant pain radiating to the right scapula, fever and anorexia. Temperature 38.6 °C, pulse 104/min and irregular, blood pressure 134/76 mmHg, respiratory rate 20/min, oxygen saturation 96% on air. There is marked tenderness and a positive Murphy sign in the right hypochondrium; no mass is felt and there is no generalised peritonitis. WBC 15.2 × 10^9/L, CRP 184 mg/L, total bilirubin 38 µmol/L, alkaline phosphatase 214 U/L, ALT 58 U/L, lipase normal, creatinine 104 µmol/L, INR 3.4. Ultrasound shows a distended gallbladder, wall thickness 6 mm, pericholecystic fluid, multiple calculi and a 4 mm non-dilated common bile duct. There is no free air and no intrahepatic duct dilatation. He is functionally independent, ASA II, BMI 29, and has had no previous abdominal surgery. The consultant surgeon is off-site; a senior registrar is covering.
1. Grade the severity and state whether he needs an operation during this admission. What information is still missing?
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Grade I (mild) acute calculous cholecystitis by the Tokyo Guidelines 2018.
- Not Grade III: there is no organ dysfunction - blood pressure, creatinine, conscious level and platelet count are all acceptable.
- Not Grade II: WBC 15.2 (not above 18), no palpable mass, symptoms under 72 hours, and no gangrenous, emphysematous or abscess-forming change on ultrasound.
He should have an early laparoscopic cholecystectomy - within 24 hours of diagnosis and certainly within 72 hours of symptom onset. In Grade I disease in a fit ASA II patient, early surgery shortens hospital stay and reduces readmission, conversion and wound infection compared with delayed 'cooled' surgery. The fact that the consultant is off-site is an organisational problem, not a clinical reason to wait; a supervised senior registrar operating in-hours with consultant telephone support is a reasonable arrangement, and if the registrar is not competent to perform it the case should be transferred or the consultant called in.
Missing information
- The CHA2DS2-VASc score and the indication for anticoagulation, because the perioperative plan depends on it.
- Whether the bilirubin of 38 µmol/L is from sepsis or from a passed stone - the 4 mm duct argues against obstruction, but repeat liver function tests in 12–24 hours are needed; if bilirubin and alkaline phosphatase rise, arrange MRCP rather than proceeding blindly.
- Baseline renal function, an ECG, group and save, and the patient's own preference after a proper consent conversation about conversion risk and bleeding.
2. His INR is 3.4. Detail exactly how you would prepare him for theatre and what you would do about his warfarin afterwards.
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Reversal
- Vitamin K 3–5 mg intravenously (2–5 mg orally if surgery can wait 12–24 hours).
- Because theatre is planned within 6–12 hours, add a 4-factor prothrombin complex concentrate 25–50 IU/kg; it corrects the INR within minutes. Fresh frozen plasma 10–15 mL/kg is an alternative only if PCC is unavailable - it works more slowly and risks volume overload in a 68-year-old.
- Target INR below 1.5 before incision. Anaesthetists and surgeons should not accept 'INR 2.0 and falling'; laparoscopic ports and any conversion to open surgery involve deep dissection.
- Recheck INR at 60 minutes and again immediately before transfer to theatre. Remember that the half-life of PCC is short and the INR will rebound unless vitamin K has also been given.
Around the operation
- No therapeutic low-molecular-weight heparin in the immediate preoperative window. Start prophylactic LMWH (for example enoxaparin 40 mg daily, renally adjusted) 6–12 hours postoperatively once haemostasis is secure.
- Group and save; correct any anaemia; ensure the anaesthetist knows the reversal history.
Afterwards
- Restart warfarin at his usual dose once he is eating, and bridge with therapeutic LMWH until the INR is back in the 2.0–3.0 range. Involve cardiology if the CHA2DS2-VASc score is high, but a short interruption for urgent surgery is generally accepted.
- Document the reason for the reversal and give him a written anticoagulation plan on discharge - INR monitoring, interactions, and what to do if bleeding occurs.
3. Overnight the registrar is alone and the patient develops a temperature of 39.1 °C with a rising CRP. How does your decision change, and when would you place a percutaneous cholecystostomy?
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Escalation. New fever and rising CRP within hours of admission suggest progression towards Grade II/III disease or a complication (perforation, pericholecystic abscess, ascending cholangitis). Reassess the abdomen for generalised peritonitis and check blood pressure, lactate, urine output and conscious level against the Tokyo Grade III criteria. Repeat bloods, take cultures, start antibiotics if not already given, and arrange urgent senior review.
Decision time
- If the patient is stable and the INR can be corrected within a few hours, proceed to laparoscopic cholecystectomy under consultant cover - the registrar should call the consultant in rather than operate beyond their competence.
- Percutaneous cholecystostomy under local anaesthetic and ultrasound guidance is the rescue option for a patient who is too unstable or too comorbid for general anaesthesia, or in whom reversal cannot be achieved safely. It controls the septic source and buys time; interval cholecystectomy should follow in 6–8 weeks once the anticoagulation and fitness have been optimised. It is not a definitive treatment and carries tube-related complications, so it should not be chosen simply because theatre is busy.
- If there is evidence of choledocholithiasis or cholangitis (rising bilirubin, dilated duct), ERCP comes before or with cholecystostomy.
Communicate the reasoning to the patient and family: the operation is being delayed or replaced because of bleeding risk and physiological state, not because his pain is unimportant.