Case Study: Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis

Abstract

This case study presents a 42-year-old female who arrived with acute right upper quadrant abdominal pain, fever, and vomiting. Diagnostic evaluation revealed gallstones with gallbladder wall thickening and a positive sonographic Murphy’s sign, consistent with acute calculous cholecystitis. Early laparoscopic cholecystectomy was performed within 24 hours of admission, resulting in rapid symptom resolution and an uncomplicated recovery. This case highlights the importance of prompt diagnosis, early surgical intervention, antibiotic coverage, and postoperative care in effectively treating acute cholecystitis and preventing complications such as perforation or biliary sepsis.

Introduction

Acute calculous cholecystitis is one of the most common causes of emergency abdominal admissions and typically results from cystic duct obstruction by gallstones. This obstruction leads to gallbladder distension, ischemia, and bacterial colonization, contributing to inflammation and infection. Laparoscopic cholecystectomy remains the gold standard treatment, offering shorter recovery time, lower complication rates, and reduced hospital stays compared to open surgery.

This case demonstrates the structured evaluation, perioperative management, and postoperative care pathway followed in acute cholecystitis, emphasizing the benefits of early surgical intervention and adherence to established treatment guidelines.

Patient Information

• Age / Gender: 42-year-old female

• BMI: 29 kg/m²

• Medical History: Dyslipidemia, intermittent dyspepsia

• Surgical History: None

• Family History: Mother with history of gallstones

• Dietary History: High-fat diet; frequent consumption of fried foods

• Social History: Non-smoker; no alcohol use

• Chief Complaints: Sudden right upper quadrant abdominal pain, nausea, and high-grade fever for 12 hours

Clinical Findings

Symptoms

• Severe right upper quadrant pain radiating to the back

• Persistent nausea and two episodes of vomiting

• Fever and chills

• Pain aggravated by deep inspiration

General Examination

• Temperature: 101.8°F

• Heart Rate: 118 bpm (tachycardia)

• Respiratory Rate: 22/min

• Blood Pressure: 110/70 mmHg

• Abdomen: Tenderness in right upper quadrant; rebound tenderness minimal

• Murphy’s Sign: Positive

• Jaundice: Absent

Assessment

Findings were consistent with acute calculous cholecystitis, necessitating urgent imaging and surgical evaluation.

Timeline

Day 1 Morning: Sudden onset severe RUQ pain with vomiting.
Day 1 Afternoon: Consultation at emergency department; initial labs and ultrasound ordered.
Day 1 Evening: Diagnosis of acute calculous cholecystitis confirmed; IV antibiotics initiated.
Day 2 Morning: Laparoscopic cholecystectomy performed.
Day 2 Evening: Early ambulation and clear liquids tolerated.
Day 3 Morning: Pain significantly improved; transitioned to soft diet.
Day 3 Evening: Discharged with postoperative precautions.
2-Week Follow-Up: Incisions healed; no pain, full recovery.

Diagnostic Assessment

Laboratory Findings

• WBC Count: 15,800 /µL (elevated)

• CRP: Elevated

• LFTs: Mildly elevated ALP and GGT

• Serum Bilirubin: Normal

• Amylase/Lipase: Within normal range

Ultrasound Findings

• Gallbladder distension

• Gallstones obstructing the cystic duct

• Gallbladder wall thickness: 5.2 mm

• Pericholecystic fluid present

• Positive sonographic Murphy’s sign

Interpretation

Results confirmed acute calculous cholecystitis with early inflammation and no signs of perforation or gangrene.

Therapeutic Intervention

Step 1 – Initial Stabilization

• IV fluids (normal saline)

• IV broad-spectrum antibiotics (ceftriaxone + metronidazole)

• Analgesics and antiemetics

• NPO status

Step 2 – Laparoscopic Cholecystectomy

• Four-port laparoscopic approach

• Identification and clipping of cystic artery and cystic duct

• Removal of inflamed gallbladder containing multiple stones

• No bile duct injury or bleeding complications

• Procedure completed in 65 minutes

Step 3 – Postoperative Care

• Early mobilization

• Clear liquids after 6 hours

• Oral analgesics from day 1 post-surgery

• Discharge with dietary guidance: low-fat diet for 4 weeks

Step 4 – Pathology

Histology confirmed acute calculous cholecystitis with transmural inflammation.

Challenges Faced

• Moderate intraoperative adhesions requiring careful dissection

• Elevated inflammatory markers requiring extended antibiotic coverage

• Mild postoperative nausea resolved with antiemetics

Follow-Up and Outcomes

At the two-week follow-up:

• Incision sites well healed

• Pain-free with normal activity

• No postoperative complications such as bile leak or wound infection

• Able to resume regular diet gradually

At one month:

• Returned to full work duties

• No recurrent abdominal symptoms

• Overall excellent postoperative recovery

Discussion

This case highlights key principles of managing acute calculous cholecystitis, particularly the importance of rapid diagnosis and early surgical intervention. Performing a laparoscopic cholecystectomy within the first 24–72 hours of symptom onset is associated with shorter hospital stays, reduced complications, and faster recovery. In this patient, preoperative imaging and laboratory findings guided timely decision-making, while perioperative antibiotics and careful surgical technique minimized the risk of postoperative infections.

Additionally, early risk stratification using clinical scores and ultrasound findings supported the decision for urgent surgery rather than delayed management. The anesthesiology team optimized the patient’s comorbidities preoperatively, helping reduce perioperative risk and ensuring stable intraoperative hemodynamics. Early mobilization and resumption of oral feeding further enhanced recovery, supporting current enhanced recovery after surgery (ERAS) principles.

Comprehensive patient education regarding diet modifications, wound care, activity restrictions, and recognition of warning signs such as fever, jaundice, bile leak symptoms, or severe abdominal pain was crucial to ensuring a smooth postoperative course. This case reinforces the value of a standardized, evidence-based treatment pathway and a multidisciplinary approach involving surgeons, anesthesiologists, nursing staff, dietitians, and postoperative care providers, all contributing to improved outcomes and patient satisfaction.

Key Takeaways

• Early laparoscopic cholecystectomy is the gold standard for acute cholecystitis.

• Ultrasound plays a central role in diagnosis through visualization of gallstones and gallbladder inflammation.

• Prompt antibiotic therapy and IV resuscitation improve preoperative stability.

• Postoperative recovery is typically rapid with minimally invasive surgery.

• Patient education ensures long-term dietary and lifestyle modification.

Patient’s Perspective

“I had severe pain that scared me, but once the doctors explained the problem and the surgery, I felt reassured. The laparoscopic procedure was much easier than I imagined, I was able to walk the next day. Within a week, I felt almost normal, and now I can eat without worrying about sudden pain.”

Conclusion

This case illustrates the importance of early recognition and timely surgical intervention in acute calculous cholecystitis. Laparoscopic cholecystectomy remains the treatment of choice, offering rapid symptom relief, fewer complications, and quicker return to normal activities. A comprehensive approach involving clinical evaluation, ultrasound confirmation, effective antibiotic therapy, and meticulous surgical technique ensures optimal outcomes. Patient education on lifestyle modifications and postoperative care further contributes to long-term gastrointestinal well-being.

Moreover, this case highlights how swift diagnosis and coordinated multidisciplinary care from emergency clinicians to surgeons and nursing teams can prevent progression to severe complications such as gallbladder perforation, empyema, or biliary sepsis. Emphasizing early mobilization, structured pain control, and careful dietary reintroduction supports smoother recovery and reduces postoperative discomfort. Long-term follow-up reinforces adherence to healthy dietary habits, helps identify rare late complications, and empowers patients to take an active role in maintaining digestive health. Overall, this case underscores that optimal management of acute cholecystitis relies on timely intervention, patient-centered care, and continual postoperative guidance.

References

1. Tokyo Guidelines 2018 (TG18) for the management of acute cholecystitis and cholangitis.
   Hirota M, Takada T, Kawarada Y, et al. Tokyo Guidelines 2018: Diagnostic criteria and severity grading of acute cholecystitis. Journal of Hepato-Biliary-Pancreatic Sciences. 2018.

2. World Society of Emergency Surgery (WSES) Guidelines (2020).
   Pisano M, Allievi N, Gurusamy K, et al. 2020 WSES guidelines for the diagnosis and treatment of acute calculous cholecystitis. World Journal of Emergency Surgery. 2020.

3. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Clinical Guidelines.
   SAGES Guidelines Committee. Guidelines for the clinical application of laparoscopic biliary tract surgery. SAGES Publications.

4. New England Journal of Medicine – Review on Acute Cholecystitis.
   Yokoe M, et al. Acute Calculous Cholecystitis. NEJM. 2021.

5. American College of Gastroenterology (ACG) guidance on gallstone disease.
   Shaffer EA. Epidemiology and risk factors for gallstone disease. ACG Clinical Updates.

6. European Association for Endoscopic Surgery (EAES) Guidelines for Laparoscopic Cholecystectomy.
   Bouillot JL, Fingerhut A, et al. EAES guidelines for endoscopic surgery: Laparoscopic cholecystectomy. Surgical Endoscopy.

7. UpToDate – Acute Calculous Cholecystitis: Clinical Manifestations and Management.
   UpToDate. Acute calculous cholecystitis in adults: Clinical features and diagnosis.

8. World Health Organization (WHO) – Surgical Care and Essential Surgery Guidelines.
   WHO. Surgical care at the district hospital: Gallbladder diseases and cholecystectomy guidance.

9. Gallbladder Pathology Reference.
   Albores-Saavedra J, Henson DE, et al. Tumors of the Gallbladder, Extrahepatic Bile Ducts, and Ampulla of Vater. AFIP Atlas of Tumor Pathology.

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