Acute cholecystitis in a patient four months after a drug-eluting coronary stent
Mr B, 71, presents at 02:00 with three days of right upper quadrant pain, fever of 38.7 °C, heart rate 112, blood pressure 128/74, respiratory rate 20 and SpO2 96% on air. White cell count is 17.4 × 10⁹/L, CRP 232 mg/L, bilirubin 34 µmol/L, ALP 210 U/L, ALT 58 U/L, creatinine 138 µmol/L against a baseline of 95, eGFR 44. Ultrasound shows an 11 cm gallbladder with a 6 mm wall, pericholecystic fluid and a stone impacted at the neck; the common bile duct is not dilated. Four months ago he had a drug-eluting stent for an NSTEMI and takes aspirin 75 mg and ticagrelor 90 mg twice daily; cardiology has told him both must continue for 12 months. Metformin was held on admission and his capillary glucose is 14 mmol/L. He is alert, passing urine, and has no organ dysfunction. The theatre list is full with two laparotomies and the consultant is off site.
1. Classify the severity of this cholecystitis and justify your management plan for the next 24 hours, including whether he needs an operation tonight.
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Severity: grade II (moderate) on the Tokyo Guidelines.
Grade III requires organ dysfunction: cardiovascular (systolic below 90 mmHg or need for vasopressors), neurological, respiratory (PaO2/FiO2 below 300), renal (oliguria or creatinine above 2 mg/dL, roughly 177 µmol/L) or hepatic (INR above 1.5). His creatinine of 138 µmol/L is above his baseline but does not meet the renal threshold; he is normotensive, alert and passing urine. Grade II is supported by symptoms beyond 72 hours and marked local inflammation on ultrasound (6 mm wall, pericholecystic fluid).
Next 24 hours: crystalloid resuscitation, nil by mouth, intravenous antibiotics covering Enterobacterales and anaerobes (for example piperacillin–tazobactam dose-adjusted to eGFR 44), analgesia, antiemetics, thromboprophylaxis once bleeding risk is assessed, hourly urine output, 6-hourly observations and a repeat lactate. Treat the hyperglycaemia with a variable-rate insulin infusion; a glucose of 14 mmol/L alongside sepsis worsens outcomes.
Surgery tonight: no. Early laparoscopic cholecystectomy is the standard for grade II, but 'early' means within 24–72 hours of presentation, not before the antiplatelet question is settled. Ticagrelor is a reversible P2Y12 inhibitor with an offset of 3–5 days; operating on it carries a real bleeding risk, while stopping it four months after a drug-eluting stent risks stent thrombosis. That is a same-day three-way conversation between surgery, cardiology and anaesthesia. If surgery is agreed, continue aspirin, stop ticagrelor 3–5 days beforehand with cardiology agreement, and operate where blood products are available. If dual therapy must continue, drain the gallbladder instead. If he develops organ dysfunction, the plan becomes urgent drainage regardless of antiplatelets.
2. The consultant messages you to book him for laparoscopic cholecystectomy on tomorrow's list. What do you do, what do you communicate, and to whom?
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Do not book unilaterally, and do not simply comply to avoid friction. The consultant is entitled to make the decision, but must make it with the relevant facts in front of them.
- Call the consultant back rather than exchanging messages. State the concern in neutral, factual terms: ticagrelor with a 3–5 day offset, drug-eluting stent four months ago, ongoing dual therapy, grade II disease with no organ dysfunction, and the alternative of drainage and delayed surgery.
- Request a documented plan. If they still want to operate tomorrow, ask for a same-day cardiology opinion and anaesthetic review, and confirm the agreed plan in the notes and by email.
- Escalate if necessary. If the consultant is uncontactable or dismissive, speak to the on-call consultant surgeon or clinical director. This is a foreseeable-harm issue, not a hierarchy issue.
- Consent properly. The patient must hear the risk of bleeding requiring transfusion or reoperation, the risk of stent thrombosis if ticagrelor is stopped, and the alternative of percutaneous drainage with cholecystectomy after dual therapy can be modified.
- Default to the safer option while the question is open: antibiotics, resuscitation and drainage. A cholecystostomy today does not prevent an elective operation later, whereas a coronary event or a reoperation for bleeding may be irreversible. Document contemporaneously.
3. If a percutaneous cholecystostomy is placed, what are the follow-up obligations and the criteria for later cholecystectomy?
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A cholecystostomy is a bridge, not a destination, and it fails silently if nobody owns it.
Immediately: confirm tube position with contrast or CT, secure it with a suture, document the volume and character of output, and review the patient at 48–72 hours for clinical and biochemical improvement. Failure to improve should prompt a check of tube position and a search for undrained pus or a blocked cystic duct. Antibiotics should run for a defined course and then stop.
Removal: the tract needs at least two to three weeks to mature. Typical practice is a tube cholangiogram at 2–3 weeks to confirm cystic duct patency and a clear common bile duct, then a clamping trial for 24–48 hours; remove only if the patient remains well. If the cystic duct is not patent, leave the drain and refer for definitive surgery. Removing a drain early, or having it fall out, is a well-recognised cause of biliary peritonitis.
Definitive surgery: recurrence after removal is common, so cholecystectomy should be planned rather than hoped for. The window is once cardiology allows ticagrelor to be stopped - usually after 12 months of dual therapy, or earlier if the stent is low risk and the patient can be switched to clopidogrel. Book interval review, give the patient a written plan, and ensure the referral is made before discharge rather than left to the patient to chase.