Cholecystectomy in a Patient with Blood Thinners

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.

Post surgery, the patient was monitored in the general ward for 2 days. The drain was removed on post-op day 2. The patient remained stable and was discharged well on the same day. 

His final histology of the gallbladder revealed acute chronic cholecystitis. Mr T was reviewed in the clinic a week after surgery and he was generally well with no significant issues.

This case highlights the successful management of complicated severe gallbladder infection in a high-risk patient with multiple health conditions and medications, including use of potent blood thinner. Timely surgical intervention and good clinical acumen were important to avoid delay in treatment that may result in worsening of patient’s condition and potentially life-threatening sepsis.  A good clinical acumen, careful monitoring, patient-centred care with regular update/ communication with patients and well-equipped surgical skills have helped to achieve favourable outcomes in this case, even in the presence of severe inflammation with underlying significant medical conditions. 

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.