WBR0822
| Author | PageAuthor::Vendhan Ramanujam |
|---|---|
| Exam Type | ExamType::USMLE Step 3 |
| Main Category | MainCategory::Emergency Room |
| Sub Category | SubCategory::Gastrointestinal, SubCategory::Hepatology |
| Prompt | [[Prompt::A 65 year old male comes to the ER with complaints of acute sharp and cramping right upper abdominal pain, 8/10 in severity, spreading to his right shoulder blade and worsening over the past six hours. The pain is accompanied by nausea and vomiting. He is a known alcoholic cirrhotic patient. His vital signs are heart rate 112 beats/min, respiratory rate 20/minute, blood pressure 100/60 mm Hg and oral temperature 39.2 C. On physical examination yellowing of his skin and sclera are obvious, and abdominal examination elicits guarding and tenderness without rigidity. Emergency serum biochemistry tests were ordered and it revealed the following results
 |
| Answer A | AnswerA::Observation over the next 24 to 48 hours along with conservative management like nil per oral, naso gastric tube, intravenous fluids, antibiotics, analgesics and antiemetics |
| Answer A Explanation | [[AnswerAExp::Incorrect-Symptomatic and uncomplicated patients who are at reduced or no risk for progression towards complication like abscess formation or gallbladder perforation can be observed for the next 24 to 48 hours along with conservative management like keeping the patient on nil per oral with naso gastric tube, and intravenous fluids along with antibiotics, analgesics and antiemetics. If the patient condition deteriorates, an emergency cholecystectomy should be done. If his condition improves, an elective cholecystectomy can be done after 48 hours or when the inflammation subsides.]] |
| Answer B | AnswerB::Observation alone over the next 24 to 48 hours |
| Answer B Explanation | AnswerBExp::'''Incorrect'''-Observation should usually be accompanied by conservative treatment while managing uncomplicated acute cholecystitis patients. |
| Answer C | AnswerC::Emergency laparoscopic cholecystectomy |
| Answer C Explanation | [[AnswerCExp::Correct-In acute cholecystitis patients with high fever (>102.2 C), marked leukocytosis (>15,000 WBC), or chills suggesting suppurative progression, immediate laparoscopic cholecystectomy (within 24 hours) is the management of choice, which is known to be a safe procedure, shortening the hospital length of stay.]] |
| Answer D | AnswerD::Emergency open cholecystectomy |
| Answer D Explanation | [[AnswerDExp::Incorrect-A laparoscopic cholecystectomy is more effective, with fewer complications and can be done more quickly during emergency when compared to open procedure. If the patient is not medically stable for cholecystectomy, percutaneous aspiration is an option.]] |
| Answer E | AnswerE::Percutaneous cholecystectomy |
| Answer E Explanation | [[AnswerEExp::Incorrect-Patients who are not good surgical risks but who are toxic may benefit from percutaneous gallbladder drainage and placement of a cholecystostomy or T-tube if common bile duct stones are suspected. The alternative is ERCP, to attempt endoscopic opening of the common bile duct or cystic duct.]] |
| Right Answer | RightAnswer::C |
| Explanation | [[Explanation::The incidence of cholelithiasis is as high as 46% in cirrhotic patients, which usually progresses to acute cholecystitis. About 10% of patients with acute cholecystitis require emergency treatment. These are cases in which the disease appears to have become complicated or are about to. High fever (>102.2 C), marked leukocytosis (>15,000 WBC), or chills suggest suppurative progression. Acalculous acute cholecystitis is also placed in this category. Other signs of complications such as worsening abdominal pain (gallbladder perforation) or the appearance of an abdominal mass (abscess formation) are a reason for surgery. Immediate laparoscopic cholecystectomy (within 24 hours) has been increasingly performed by surgeons, because it has been shown to be safe, is not more difficult than laparoscopic cholecystectomy performed later, and shortens the hospital length of stay.
Educational Objective:
In an acute cholecystitis patient, high fever (>102.2 C), marked leukocytosis (>15,000 WBC), or chills suggest suppurative progression. Acalculous acute cholecystitis is also placed in this category. Other signs of complications are worsening abdominal pain (gallbladder perforation) or the appearance of an abdominal mass (abscess formation). Immediate laparoscopic cholecystectomy (within 24 hours) is the management of choice, because it has been shown to be safe, is not more difficult than laparoscopic cholecystectomy performed later, and shortens the hospital length of stay. |
| Approved | Approved::Yes |
| Keyword | WBRKeyword::Cholelithiasis, WBRKeyword::Acute cholecystitis, WBRKeyword::Cholecystectomy |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |