Q88). A 75 year old woman is sent from the nursing home for evaluation of fever and altered mental status. The patient’s past medical history is significant for moderate Alzheimer’s dementia. On examination, she is confused. Her vitals reveal Temperature of 102F, Blood pressure 80/60 and a HR of 102/min. Chest and cardiovascular examination is benign. On abdominal examination, the patient moans upon palpation of right upper quadrant. Cholecystitis is suspected and ultrasound is obtained that reveals very distended gall bladder with pericholecystic fluid, a normal caliber common bile duct and a gall stone in the cystic duct. The patient is started on IV Normal saline and broad spectrum antibiotics. Her blood pressure despite initial hydration is still 80/40. She is started on Norepinephrine drip. The next most important step in managing this patient ?
A. Urgent Cholecystectomy
B. Endoscopic Retrograde Cholangiopancreatography
C. Percutaneous Cholecystostomy
D. 2D echocardiogram
E. Exploratory Laporotomy
B
b
This is an emergency
u must releive the distention NOW
C is the answer
ccc
C
Mild Sx – observe if stable, early lap chole if unstable
Moderate Sx – early lap chole if stable, percutaneous gb drainage if unstable
Severe Sx including organ dysfunction (cardio-hypotension, neuro-decreased consciousness, pulm-respiratory distress, renal-Cr > 2, hepatic-pt/inr abnormal, hem-thrombocytopenia) – IVF & IV abx, percutaneous drainage, if unstable then early chole
In all cases if percutaneous drainage is done, follow up with elective lap chole.
http://www.med.upenn.edu/gastro/documents/GastroClinNAcholecystitisandcholangitis.pdf