A 71-year-old male with past medical history of hypertension, hyperlipidemia, congestive heart failure with 20% ejection fraction, and chronic obstructive pulmonary disease on 3 L home oxygen presents to the emergency department from his nursing home with complaints of: 5 days of fever, nausea, and right upper quadrant abdominal pain. His vital signs are as follows:
He undergoes an ultrasound that shows cholelithiasis, gallbladder wall thickening with pericholecystic fluid, and a positive sonographic Murphy sign, consistent with a diagnosis of acute calculous cholecystitis.
What is the most appropriate management?
Correct Answer: E
Acute calculous cholecystitis is inflammation of the gallbladder in the presence of gallstones and obstruction of the cystic duct. Typical management involves initiation of antibiotic therapy and surgical cholecystectomy if the patient is an appropriate candidate. The patient presented above is a high surgical risk candidate given his multiple comorbidities and poor baseline functional status. Therefore, it would not be advisable to proceed with operative intervention at this time including laparoscopic or open cholecystectomy. In the setting of sepsis and presentation >72 hours after onset of symptoms it is unlikely that intravenous antibiotics alone will lead to resolution, although initiation of antibiotic therapy within 6 hours is recommended, or within 1 hour in patients presenting in septic shock. Endoscopic retrograde cholangiopancreatography is a procedure performed for a variety of reasons, including common bile duct obstruction in choledocholithiasis or cholangitis, but it is not typically used to address cystic duct obstruction in the setting of acute cholecystitis. The most appropriate management of this patient would include placement of a percutaneous cholecystostomy tube under ultrasound guidance. This allows for decompression of the gallbladder and can be done under local anesthesia and thus places minimal physiologic strain on this unstable and comorbid patient. The success rate for percutaneous cholecystostomy tube for the treatment of calculous cholecystitis is over 90% with a complication rate (most importantly bleeding and bile leakage) of less than 10%. Typically, these tubes remain in place for a minimum of 4 to 6 weeks, at which time further evaluation is performed with cholangiography, and a decision can be made about the need for elective cholecystectomy.
A 65-year-old male is now 10 days status post coronary artery bypass grafting with a postoperative course complicated by bleedingrequiring reoperation, and ventilator-associated pneumonia. After being afebrile for 2 days he spikes a temperature to 102°F and his laboratory test results demonstrate a new leukocytosis. An abdominal ultrasound is obtained that shows a distended gallbladder with wall thickening and pericholecystic fluid. A computed tomography scan of his abdomen confirms the aforementioned findings and is otherwise unremarkable.
From the following choose the correct diagnosis and treatment.
Correct Answer: B
Acalculous cholecystitis is an inflammatory disease of the gallbladder, which occurs in the absence of gallstones and is multifactorial in etiology. Acalculous cholecystitis accounts for approximately 10% of cases of acute cholecystitis and is typically seen in critically ill patients, such as the one described above. Risk factors for acalculous cholecystitis include, but are not limited to, major trauma, burns, sepsis, prolonged total parenteral nutrition, and congestive heart failure. Diagnosis involves high clinical suspicion of the clinician in the appropriate clinical setting and can be confirmed with standard laboratory evaluation and imaging studies including either ultrasonography or computed tomography. In cases where the diagnosis is still uncertain, cholescintigraphy (HIDA scan) can be used. Delay in treatment can result in bacterial superinfection and potential gallbladder perforation. In addition to initiation of antibiotic therapy, definitive therapy with either cholecystectomy or gallbladder drainage is warranted. Of the above choices, Answer B provides the correct diagnosis (acalculous cholecystitis) and the most appropriate method of gallbladder drainage (percutaneous cholecystostomy tube) in the setting of recent cardiac surgery and critical illness. Endoscopic retrograde cholangiopancreatography does not provide appropriate gallbladder decompression as mechanical obstruction is not the cause in acalculous cholecystitis.
A 45-year-old female with a past medical history of obesity and cholelithiasis presents to the emergency department with 2 days of right upper quadrant abdominal pain, fevers, and emesis. She is febrile to 102°F and her systolic blood pressure in the 80s mm Hg. Her systolic blood pressure improves to the 100s with 2 L lactated ringers. Her laboratory test results are notable for a WBC count of 19,000/mm3 (85% neutrophils), total bilirubin 6 mg/dL, and amylase 130 U/L. An abdominal ultrasound is obtained in the emergency department that shows cholelithiasis, a common bile duct measuring 8 mm and an otherwise normal gallbladder. In addition to continued resuscitation with IV fluids, what is the most appropriate next step in management?
Correct Answer: D
Acute cholangitis, or ascending cholangitis, is the result of stasis and subsequent infection of the biliary tract typically due to mechanical obstruction. The most common etiology of obstruction is biliary calculi, although other causes include benign and malignant strictures and biliary stent obstruction. Charcot triad of fever, abdominal pain, and jaundice is the classic presentation, with the addition of hypotension and altered mental status forming Reynold Pentad, which is indicative of more severe cholangitis with associated septic shock. Diagnosis is made with a high clinical suspicion, laboratory values including a leukocytosis with neutrophil predominance and a cholestatic pattern of liver tests (predominantly conjugated bilirubinemia) and imaging with biliary ductal dilatation or visualization of the underlying cause of obstruction. Imaging modalities include ultrasound, computed tomography, or magnetic resonance cholangiopancreatography. In addition to resuscitation with isotonic crystalloid solution and initiation of antibiotic therapy, it is important to address the need for biliary ductal decompression or resolution of persistent biliary obstruction. In the patient above presenting with acute cholangitis and concerns for persistent biliary obstruction (total bilirubin 6 mg/dL, common bile duct measuring 8 mm) antibiotics alone will not be sufficient. Although a percutaneous cholecystostomy tube will aid in decompression of the biliary tree, it does not address the distal common bile duct obstruction and therefore is not the best first line option. Given that the patient’s cholangitis is likely due to choledocholithiasis (gallstones obstructing the common bile duct), she may eventually benefit from a cholecystectomy to prevent recurrent episodes of choledocholithiasis, but cholecystectomy at this time will not address her ongoing bile duct obstruction. Although percutaneous transhepatic cholangiography performed by Interventional Radiology decompresses the biliary tree and may be able to address more distal obstructions, it is a technically difficult procedure that typically requires intrahepatic ductal dilatation and is not currently first line therapy when a gastroenterologist is available to perform endoscopic retrograde cholangiopancreatography and the patient’s anatomy is amenable to it.
A 50-year-old male with a past medical history of hypertension presents to the emergency department with right upper quadrant abdominal pain, nausea, and fevers. He is noted to have an elevated white blood cell count and total bilirubin of 5 mg/dL. Further evaluation with an abdominal ultrasound shows a dilated common bile duct to 8 mm with a visualized obstructing gallstone within the lumen. All of the following are appropriate antibiotic choices EXCEPT:
Empiric antibiotic choices should include those with coverage of enteric pathogens, which can later be narrowed based on culture data. Most common pathogens include gram negative aerobic enteric organisms (Escherichia coli, Enterobacter species, Klebsiella species), gram positive organisms (Streptococcus and Enterococcus species) and anaerobes. Though unlikely in this patient, history of healthcare-associated infections or infection with drug-resistant organisms may require additional empiric coverage. All choices except ceftriaxone are effective against the spectrum of common pathogens relevant in ascending cholangitis. Though ceftriaxone is effective against various gram positive and negative organisms, it is not effective against anaerobes.
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