Acute cholecystitis in a patient on a direct oral anticoagulant

Grading

Using the Tokyo Guidelines (TG18) grading, this is grade II (moderate) acute cholecystitis: symptom duration over 72 hours plus marked local inflammation with guarding and a positive Murphy sign, and a white cell count approaching 18. It is not grade III, because there is no organ dysfunction - he is normotensive, alert with a normal creatinine, and adequately oxygenating. This distinction matters because grade II is generally managed with early surgery, while grade III often needs drainage first.

Initial management

• Resuscitation and monitoring: IV crystalloid, hourly observations, fluid balance, and repeat bloods including lactate.
• Analgesia: regular paracetamol and an opioid for breakthrough. Avoid NSAIDs given his diabetes, age and renal risk.
• Antiemetic and nil by mouth initially, though early light diet is acceptable if he tolerates it.
• Antibiotics covering enteric gram-negatives and anaerobes - for example amoxicillin-clavulanate, or ceftriaxone plus metronidazole - according to the local guideline. Take blood cultures first.
• Anticoagulation: apixaban is held. He needs mechanical thromboprophylaxis (intermittent calf compression) until it is safe to restart.
• Glycaemic control: check capillary glucose regularly and use a variable-rate insulin infusion if he is hyperglycaemic and not eating.
• Investigations: repeat LFTs, and if the bilirubin rises or the duct dilates, consider an additional common bile duct stone and the need for MRCP or ERCP.
• Escalation: a senior general surgical review the same day, with an anaesthetic assessment, and a documented plan for the definitive procedure rather than open-ended conservative management.

The two options

1. Early laparoscopic cholecystectomy during the index admission, ideally within 24 hours of admission and within about 72 hours of symptom onset. For grade I-II disease this is the standard of care: it shortens hospital stay, reduces recurrence and wound infection, and does not increase bile duct injury when done by an experienced surgeon. Local inflammation makes it technically harder, so it should be done in daylight by a surgeon who does this regularly.
2. Conservative treatment with antibiotics then interval cholecystectomy at about six weeks, used when theatre access, surgical fitness or the degree of inflammation makes early surgery unsafe. He needs to be told the risk of failure of conservative management - recurrent cholecystitis, pancreatitis or ascending cholangitis in the interim.

Managing the apixaban

• His last dose was 14 hours ago and his eGFR is 74. For a laparoscopic cholecystectomy, a low-to-moderate bleeding risk procedure, apixaban is usually withheld for about 24-48 hours pre-operatively at this renal function. That fits comfortably with a plan to operate the following morning under antibiotics and observation.
• Do not bridge with low molecular weight heparin. In DOAC-treated patients bridging increases major bleeding without reducing stroke, and his stroke risk from a 48-hour hold is low.
• Restart apixaban 24-48 hours post-operatively once haemostasis is secure and there is no bleeding, and prescribe mechanical prophylaxis in the gap.
• Document a clear perioperative anticoagulation plan on the consent form and the drug chart so it is not left to chance.

Consent should cover conversion to open, bile duct injury, bleeding, anaesthetic risk in a BMI of 36 with diabetes, and the possibility of a drain.

What is happening

He has progressed to grade III (severe) cholecystitis with septic shock and multi-organ dysfunction - cardiovascular, neurological and renal. Consider the mechanisms: a gangrenous or perforated gallbladder causing localised or free peritonitis, an abscess, or ascending cholangitis (particularly if the bilirubin has risen - check the trend and the duct calibre on repeat imaging).

What to do, in order

• Sepsis resuscitation: high-flow oxygen, repeat cultures, broad-spectrum IV antibiotics, 30 mL/kg crystalloid in boluses with reassessment, then early noradrenaline via a central line to a MAP of at least 65 mmHg. Catheterise for hourly urine output. Move to HDU or ICU.
• Senior help now: consultant surgeon, anaesthetist and intensivist, not the night intern alone.
• Repeat bloods: lactate, FBC, U&E, LFTs, coagulation, blood gas, and group and crossmatch.
• Source control is the priority, but not necessarily by laparotomy. In a shocked, high-risk patient the TG18 recommendation is percutaneous cholecystostomy under radiology, with interval cholecystectomy once he has recovered. If imaging shows free perforation or generalised peritonitis, he needs an emergency laparotomy or laparoscopy regardless.
• Anticoagulation: apixaban remains on hold; he is now bleeding risk as well as stroke risk. Discuss reversal with haematology if bleeding occurs - note prothrombin complex concentrate does not reliably reverse apixaban, and specific reversal agents are not routinely available.
• Goals of care: speak to his family early, document resuscitation status, and keep them informed of the change in trajectory. Reassess the plan each time the lactate and the observations are repeated.