A 62-year-old man with diabetes and hypertension presents with severe right upper quadrant pain, fever (39.2°C), and hypotension (BP 92/58 mmHg). Examination reveals guarding and rebound tenderness. Ultrasound shows a large stone impacted in the gallbladder neck, a thickened gallbladder wall (8 mm), and free fluid in the peritoneal cavity. WBC 18,000/μL. What is the most appropriate immediate next step?

Explanation

## Clinical Diagnosis This patient has **acute cholecystitis with probable perforation** — evidenced by: - Peritoneal signs (guarding, rebound tenderness) - Hypotension and fever (sepsis) - Free intraperitoneal fluid on ultrasound - Elevated WBC ## Acute Cholecystitis: Risk Stratification ```mermaid flowchart TD A[Acute cholecystitis]:::outcome --> B{Peritoneal signs + sepsis?}:::decision B -->|Yes| C[Perforation likely]:::urgent C --> D[Urgent open cholecystectomy]:::action B -->|No| E{Fit for early LC?}:::decision E -->|Yes| F[Early LC within 72h]:::action E -->|No| G[Percutaneous cholecystostomy]:::action H[Free fluid on imaging] --> I[High risk of perforation]:::urgent ``` ## Why Immediate Open Surgery Is Correct **Key Point:** Acute cholecystitis with **peritoneal signs, sepsis, and imaging evidence of free fluid** constitutes a surgical emergency. Perforation is likely, and **immediate open cholecystectomy** is the standard of care. **High-Yield:** Do NOT delay surgery for further imaging (CT) or diagnostic procedures when clinical and ultrasound evidence strongly suggest perforation. Delay increases mortality from sepsis and peritonitis. **Clinical Pearl:** Perforation risk factors include: - Age > 50 years - Diabetes (this patient has it) - Male gender - Delayed presentation - Immunosuppression This patient has multiple risk factors and clear signs of peritonitis — surgery cannot wait. ## Why Other Options Are Wrong | Option | Why Incorrect | |---|---| | **Diagnostic laparoscopy** | Laparoscopy is contraindicated in suspected perforation with peritonitis; risk of gas embolism and inability to manage contamination | | **Percutaneous cholecystostomy** | Appropriate for unfit/high-risk patients, NOT for perforation with peritonitis; definitive surgery is required | | **CT for confirmation** | Delays definitive treatment in a septic patient; ultrasound evidence + clinical signs are sufficient; time to OR is critical | **Mnemonic: PERF-STAT** — **P**eritoneal signs, **E**levated WBC, **R**ebound tenderness, **F**ree fluid → **STAT** surgery (open, not laparoscopic). [cite:Sabiston Textbook of Surgery 21e Ch 54; Harrison 21e Ch 308]