172) A 44 year old obese woman presents with complaints of abdominal pain in the right upper quadrant that started 4 hours ago and is persistent. She has mild nausea. On physical examination, there is tenderness in right upper quadrant which increases with deep breath. Her liver function tests are normal; WBC count is 24,000/µl with neutrophilic predominance. Amylase and Lipase are with in normal limits. An ultrasound of the gall bladder reveals gall stones but there is no pericholecystic fluid or any other sonographic evidence of acute cholecystitis. Sonographic murphy’s sign is absent. The most appropriate next step in managing this patient:
A) Percutaneous Cholecystostomy
B) Laparoscopic Cholecystectomy
C) HIDA scan
D) Endoscopic Retrograde Cholangiopancreatography (ERCP)
E) Magnetic Resonance CholangiOpancreatography ( MRCP)
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An MRCP is usually done but if it is neg—it doesnt rule out cholelithiasis. An ERCP is more specific Surgery is too aggressive right now. Lets test for obstruction–ercp
hida scan
HIDA, if it doesnt show, means there r more gallstones i guess…..technically we would admit and do NPO, morphine, IVF. then later do a chole.
and theres no criteria for ERCP in this q.
oops im sorry. U/S shows gallstones, so do ERCP +/- stent and then lap chole
B) Laparoscopic Cholecystectomy
HIDA scan
No one should do an elective Cholecystectomy without confirmation that the gallbladder is indeed inflamed . Would you want me to remove your gallbladder or cut you up just because you have RUQ flank pain ?
indeed patient has risk factor : obese , early 40s ,
I would prefer HIDA because since patient is not severely ill . She can wait a while for HIDA to show up . Non invasive .
ECRCP is more hassle . And it might end up with pancreatitis as complication . Cystic duct junction is poorly visible with ERCP compared with HIDA .
would like to hear from Dr.Redz opinion and answers
Cheers
I would order ERCP, can be diagnostic and therapeutic as well. It can actually dislodge if there is a stone!! I think!
This is symptomatic biliary colic. Ultrasound shows gall stones in the gall bladder. Each time the gall bladder contracts, a gall stone obstructs the cystic duct, it causes symptoms. There is no current biliary tract obstruction, evident by normal liver function. Pancreatic function is also normal. There is no need for diagnostic studies or ‘going after’ hidden stones because her liver and pancreatic tests are normal beyond paranoia. The culprit stones are visible in the gall bladder. We know where the stones are and we know that currently there is no obstruction. Since liver and pancreatic enzyme function is normal.
Sonographic Murphy’s sign is absent suggesting pain is mild, this is the best time to do laparoscopic cholecystectomy. (before patient takes another meal and suffers probably a more severe colic)
Is it worrisome to consider surgery with his remarkable level of neutrophilia?
Neutrophilia + abnormal liver or pancreatic enzymes = alarming!
Neutrophilia alone, with no organ dysfunction, even 50,000 plus only suggest a stressful acute event.
It will take 1-5 days for levels to return to normal. It is not wise to wait that long given the risk that a biliary colic can occur again anytime most likely, within the next 24 hrs. It’s like a time bomb waiting for the next biliary contraction. (Sexual arousal, lacrimation, salivation, urination, defecation, sleep, i.e, the next parasympathetic stimulus could be another biliary colic)
I think the most appropriate next step is laparoscopic cholecystectomy. Answer is (b). If you are still not convinced, think of this as 80% symptomatic coronary or carotid stenosis. What would you do next?
We want to prevent a foreseen event. So we operate. (This is the recommended guideline for symptomatic biliary colic.)