Complex presentation of acute cholecystitis in a long-term care resident

A woman in her late 70s, residing in a long-term care facility, presented with a 2 day history of nausea and vomiting, which was later complicated by right upper quadrant pain. The patient was significantly frail, with a complex medical and drug history. She had also been recently prescribed carbamazepine for migraine prophylaxis. Initial laboratory investigations revealed significant liver enzyme derangement, and her treatment was reviewed. She was started on intravenous antibiotics, presumably treating an episode of acute cholecystitis, but an initial ultrasound (US) done at the long-term care hospital revealed a normal examination. The patient improved initially, but her symptoms recurred after 2 weeks, and she was transferred to the main hospital for further management. An abdominal CT scan revealed signs of acute acalculous cholecystitis, but magnetic resonance cholangiopancreatography (MRCP) performed a few days after confirmed acute calculous cholecystitis complicated by a type II gallbladder perforation.