WBR0917
| Author | PageAuthor::Vendhan Ramanujam |
|---|---|
| Exam Type | ExamType::USMLE Step 3 |
| Main Category | MainCategory::Inpatient Facilities, MainCategory::Emergency Room |
| Sub Category | SubCategory::Gastrointestinal, SubCategory::Hepatology |
| Prompt | [[Prompt::A 69 year old female comes to the ER with complaints of acute sharp and cramping right upper abdominal pain, 8/10 in severity, spreading to her right shoulder blade and worsening over the past six hours. The pain is accompanied by nausea and vomiting. She is a known alcoholic cirrhotic patient. She is also a known stage 3 congestive heart failure patient, who is on enalapril, spironolactone and hydrochlorothiazide. Her vital signs are heart rate 102 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 revealed the following results
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| Answer A | AnswerA::Observation over the next 24 to 48 hours and conservative management |
| 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-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 C | AnswerC::Emergency laparoscopic cholecystectomy |
| Answer C Explanation | [[AnswerCExp::Incorrect-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. In these patients 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.]] |
| 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::Correct-Worsening uncomplicated and complicated acute cholecystitis patients who are not surgical candidates with advanced pulmonary and cardiac diseases 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::E |
| 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. But the patient here is not good surgical candidate because of her advanced cardiac failure. These patients, when they 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.
Educational Objective: Uncomplicated acute cholecystitis 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. If the patient’s condition improves, an elective cholecystectomy can be done after 48 hours or when the inflammation had subsided. Uncomplicated acute cholecystitis patients not improving and worsening over the next 24 to 48 hours conservative management and complicated acute cholecystitis patients should undergo an immediate laparoscopic cholecystectomy (within 24 hours). Worsening uncomplicated and complicated acute cholecystitis patients who are not surgical candidates with advanced pulmonary and cardiac diseases 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. |
| Approved | Approved::Yes |
| Keyword | WBRKeyword::Cholecystitis, WBRKeyword::Uncomplicated cholecystitis, WBRKeyword::Complicated cholecystitis |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |