A 42-year-old woman from Delhi presents with acute right upper quadrant pain and tenderness for 6 hours. She reports fever (38.5°C), nausea, and vomiting. On examination, Murphy's sign is positive. Ultrasound abdomen shows a 1.8 cm stone in the gallbladder with wall thickening (4 mm), pericholecystic fluid, and no dilatation of the common bile duct. WBC is 12,500/μL with left shift. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis **Key Point:** This patient has acute cholecystitis (positive Murphy's sign, fever, elevated WBC, ultrasound findings of wall thickening and pericholecystic fluid) with an uncomplicated presentation — no signs of perforation, sepsis, or biliary obstruction. ## Management Strategy for Uncomplicated Acute Cholecystitis **High-Yield:** The standard of care for uncomplicated acute cholecystitis in the acute phase is **early conservative management** (within 72 hours of symptom onset) followed by **delayed cholecystectomy** (6–8 weeks later) if the patient resolves, OR **early cholecystectomy** (within 72 hours) if the patient is fit for surgery and has no contraindications. **Clinical Pearl:** In this case, the patient is haemodynamically stable, afebrile after initial fever management, and has no evidence of complications (no bile duct dilatation, no perforation signs). Initial conservative management with: - NPO status - IV fluids and electrolyte correction - Broad-spectrum antibiotics (e.g., ceftriaxone + metronidazole) - Analgesia - Serial clinical assessment allows inflammation to settle. Reassessment at 24–48 hours determines whether the patient improves (proceed to elective cholecystectomy in 6–8 weeks) or deteriorates (escalate to urgent surgery or percutaneous drainage). ## Why NOT Immediate Laparoscopic Cholecystectomy? **Tip:** While early cholecystectomy (within 72 hours) is acceptable and increasingly favoured in fit patients, the question stem does not specify acute surgical fitness or contraindication to initial medical management. The safest, most guideline-aligned first step in an uncomplicated case is trial of conservative management with reassessment. ## Why NOT ERCP or Percutaneous Drainage? - **ERCP** is indicated for **choledocholithiasis** or **biliary obstruction** (dilated CBD, elevated bilirubin). This patient has no CBD dilatation. - **Percutaneous cholecystostomy** is reserved for **acalculous cholecystitis**, **emphysematous cholecystitis**, or **unfit patients** who cannot tolerate surgery. This patient has calculous cholecystitis and is relatively fit.