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Gallbladder empyema with persistent sepsis — MRCEM SBA MCQ

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HardGastrointestinal and surgical emergenciesGallbladder empyema with persistent sepsisMRCEM SBA

A 78-year-old man is transferred from a hospital without interventional radiology after 24 hours of treatment for acute calculous cholecystitis. Ultrasound shows a distended gallbladder with an impacted neck stone and appearances consistent with empyema. The common bile duct measures 5 mm, no duct stone is seen, and bilirubin is 17 micromol/L. Despite intravenous antibiotics and fluid resuscitation, he remains febrile and requires noradrenaline; lactate is 3.5 mmol/L. The consultant surgeon and anaesthetist judge that general anaesthesia is contraindicated at present because of decompensated heart failure and ongoing shock. Resuscitation and critical care support are continuing, and interventional radiology is available. Which management plan should be arranged next?

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Correct answer: A — Arrange immediate percutaneous cholecystostomy.

This is gallbladder empyema with persistent shock despite conservative treatment. The decision turns on both parts of the exception to usual early surgery: operative treatment is contraindicated *now*, and antibiotics and resuscitation have not controlled the infection. NICE recommends percutaneous cholecystostomy in precisely this setting. Drainage should be arranged promptly alongside continuing resuscitation, antibiotics, surgical care and critical care support. Cholecystectomy can be reconsidered when he is well enough for surgery. ([nice.org.uk](https://www.nice.org.uk/guidance/cg188/resources/gallstone-disease-diagnosis-and-initial-management-35109819418309)) **B** is attractive because early laparoscopic cholecystectomy is usual treatment for acute cholecystitis, but the assessed contraindication to general anaesthesia makes it inappropriate now. **C** offers biliary drainage, but ERCP with a bile duct stent addresses ductal obstruction rather than this infected, obstructed gallbladder; neither imaging nor bilirubin suggests a common bile duct stone. **D** overlooks the deterioration during antibiotics: further treatment without source control is insufficient. **E** identifies the right procedure but gets its timing wrong. Ongoing vasopressor use increases the urgency of source control rather than establishing a reason to await its cessation. ([nice.org.uk](https://www.nice.org.uk/guidance/cg188/resources/gallstone-disease-diagnosis-and-initial-management-35109819418309))

Reference: Gallstone disease: diagnosis and management (CG188), recommendations 1.2.4–1.2.6 (29 October 2014) — https://www.nice.org.uk/guidance/cg188/resources/gallstone-disease-diagnosis-and-initial-management-35109819418309 Suspected sepsis in people aged 16 or over: recognition, assessment and early management (NG253), recommendation 1.11.4 (2025) — https://www.nice.org.uk/guidance/ng253/resources/suspected-sepsis-in-people-aged-16-or-over-recognition-assessment-and-early-management-pdf-66144015386053