Summary: This case study follows Madam A, a 95-year-old patient who was admitted with severe upper abdominal pain and diagnosed with acute necrotising cholecystitis, a serious gallbladder infection with gangrenous changes and large stones. Despite her advanced age and a post-scan asthmatic episode, Dr Lee assessed her as fit for surgery and performed a laparoscopic cholecystectomy that same evening.  Post-operative histology revealed an unexpected finding: a pre-cancerous gallbladder tumour with high-grade dysplasia that would likely have progressed to aggressive cancer had surgery been delayed. Madam A recovered well and was discharged without major complications. This case illustrates that surgical suitability in elderly patients depends on overall health condition and functional status, not age alone.

Madam A, a 95-year-old patient with a history of high cholesterol and asthma, was admitted to a private hospital under a gastroenterologist following a sudden onset of severe upper abdominal pain. She had experienced the pain earlier that day and had a longstanding history of intermittent bloating and indigestion after meals, symptoms she had never investigated. Prior to admission, she was largely independent, managing daily activities and mobilising at home without assistance.

On admission, a CT scan revealed a grossly distended gallbladder with large stones and significant inflammatory changes. Shortly after the scan, Madam A developed an acute asthmatic attack requiring inhaler and nebuliser treatment.

CT scan images of gallbladder

Madam A was referred to Dr Lee Chin Li late that evening. On assessment, her abdomen was distended and markedly tender on applying gentle pressure over the upper abdomen. She had also spiked a fever of 38.7°C. Together, these findings pointed clearly to an active infection.

Dr Lee discussed the treatment options with Madam A and her family. Two approaches were considered: a gallbladder drainage procedure followed by surgery approximately one month later (interval cholecystectomy), or proceeding directly with gallbladder removal (laparoscopic cholecystectomy).

The drainage-first approach is intended to stabilise the patient and allow the infection to settle before surgery. However, it carries its own risks: the procedure can trigger a bacterial shower that worsens the patient's condition, and if the gallbladder wall has already become necrotic (dead tissue), drainage may not be effective and perforation remains a concern.

Operating on an elderly patient who is not sufficiently stable also carries significant risk. After a joint assessment with the anaesthetist, it was determined that Madam A's breathlessness had improved with medication and that she was in reasonable health for her age. Dr Lee recommended proceeding with surgery.

Intraoperative findings confirmed a necrotic, infected gallbladder containing large stones, with pus present and gangrenous changes to the wall. The cholecystectomy was completed laparoscopically using a keyhole approach.

Intraoperative surgical images

Following surgery, Madam A was monitored in the high dependency unit for one day before being transferred to the general ward, where she remained for a further three days. Given her age, several medical issues required concurrent management, including poorly controlled blood pressure and asthma, and she was co-managed alongside other physicians throughout her stay. She also underwent intensive physiotherapy in the ward to support her recovery.

Madam A's case reflects the value of a multidisciplinary approach when managing elderly patients with acute presentations. It also underscores that surgical suitability is not determined by age alone. Overall health, functional status and careful pre-operative assessment are far more meaningful indicators of how a patient will tolerate and recover from surgery.

Laparoscopic cholecystectomy, while not considered a major procedure, carries risk like any surgery. Thorough assessment and optimisation of patient’s medical conditions, in this case conducted in collaboration with the anaesthetist and supporting physicians, allow that risk to be minimised and the best possible outcome to be achieved.

Gallbladder cancer is an aggressive and largely silent disease, rarely presenting with obvious symptoms until it has reached an advanced stage. In Madam A's case, the pre-cancerous tumour discovered on histology carried a high likelihood of malignant transformation. Without surgical intervention, she would have faced serious and potentially untreatable cancer. Early action, in this instance, was not just the right clinical decision, it may well have been lifesaving.

A 77 year old male patient, Mr T, was admitted to a private hospital in Singapore for lower chest/ upper abdominal pain with cold sweats while he was travelling back from Malaysia. He has multiple background medical issues, such as hypertension, high cholesterol, obesity, diabetes and ischaemic heart disease for which he was on a blood thinner, clopidogrel. 

He presented to the emergency department and was admitted under his cardiologist as initial suspicion was a cardiac condition given his cardiac history with previous coronary stenting in 2015. However, initial investigations including blood tests and ECG did not reveal any heart issues. The tests showed raised white cell count which was an indicator of inflammation at 13 (Normal 11). As there was no obvious cardiac cause of his pain, an ultrasound of the abdomen was performed and it revealed 2 gallstones measuring 1.2 and 1.3cm within the gallbladder. There were no inflammatory changes to the wall of the gallbladder. 

Mr T was then referred to me as he was suspected to have gallstone-related pain. His pain resolved subsequently with simple pain medications but he developed a low grade fever of 37.8C. A repeat blood test about 2 days from admission shows an increment of white cell count from 13 to 19.1. His inflammatory marker (C-Reactive Protein) was also markedly raised at >200 (normal  <5). The blood tests were highly suggestive of an inflammation of gallbladder. The patient was started on antibiotics and in view of blood thinner which was only stopped during admission, we have initially planned for an interval gallbladder surgery.   

After 48 hours of antibiotics, the patient was still having on and off fever and his white cell count did not improve as what we would have expected, despite having minimal abdominal pain. Mr T was updated on the findings and offered a surgery to remove his gallbladder. The rationale of offering surgery is such that there is a possibility of worsening gallbladder infection despite no worsening of pain, especially in patients who are obese and diabetic. The lack of improvement despite antibiotics leads to suspicion of pus formation or gangrenous gallbladder. I discussed with him and his family about the options of surgery, Laparoscopic cholecystectomy, versus drainage of gallbladder and had given my recommendation for a surgery as drainage may not improve his condition if there is gangrenous gallbladder.  

Mr T underwent a laparoscopic cholecystectomy and the findings were of necrotic, distended gallbladder with large stones. The gallbladder wall was also noted to be necrotic and inflamed. Due to the severity of inflammation and risk of postoperative fluid collection, a fine drainage tube was inserted intraoperatively. The surgery was otherwise uneventful, and it was performed using a laparoscopic (key-hole) method.

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The case presented is for educational and informational purposes only. Certain details have been modified or generalised to protect patient confidentiality in accordance with applicable data protection and medical confidentiality guidelines in Singapore.

No personally identifiable information is disclosed, and any resemblance to actual individuals is coincidental. This case does not constitute medical advice, diagnosis or treatment, and should not be used as a substitute for consultation with a qualified healthcare professional.