Challenges in Diagnosing and Managing Acute Cholecystitis in Cirrhosis.

A 64-year-old male with cirrhosis and mild ascites secondary to metabolic-associated steatotic liver disease (MASLD) presented with right upper quadrant (RUQ) abdominal pain. Initial investigations, including an abdominal ultrasound and hepatobiliary iminodiacetic acid (HIDA) scan, did not show any evidence of acute cholecystitis. However, the patient's persistent symptoms and a positive sonographic Murphy's sign raised clinical suspicion for the condition. Subsequently, a computed tomography (CT) scan confirmed the diagnosis of acute cholecystitis. Blood cultures revealed Enterococcus faecalis and Klebsiella pneumoniae, prompting targeted antibiotic therapy. Given the high operative risk associated with cirrhosis, ascites, and extensive varices, the patient was treated conservatively with intravenous antibiotics followed by oral antibiotics. He was discharged with plans for an elective laparoscopic cholecystectomy versus endoscopic ultrasound-guided cholecystostomy (EUS-GBD) after further optimization for potential liver transplantation at an advanced center. This case underscores the complexities of diagnosing acute cholecystitis in cirrhotic patients, highlights the need for vigilant re-evaluation when imaging and clinical findings diverge, and addresses the challenges of managing high-risk surgical patients.