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
Archer USMLE Step 3 Blog 
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.
Click to access GastroClinNAcholecystitisandcholangitis.pdf
pt is elderly and unstable. Do perc chole and when stable. can always remove the gallbladder after optimizing her medically.
C is the Answer. hemodynamic instability, poor surgical candidates ( several comorbidities: CHF, AF, CRF ): treatment of choice: Perc. Cholecystostomy. You need to decompress that gallbladder before it explodes! It is the fastest way to treat this patients, and wont put them into the stress of surgery.
Dr. Red, C is the answer?
Percutaneous cholecystostomy is an alternative to cholecystectomy for patients at very high surgical risk such as the elderly (as referenced in the clinical vignette),those w/ acalculous cholecystitis and those patients in the ICU because of burns, trauma,or respiratory failure.
C
The standard of care for acute cholecystitis has been laparascopic cholecystectomy–In certain high-risk patients where surgery would carry a high mortality, percutaneous cholecystostomy has been shown to be useful in treating the acute phase of acute cholecystitis. Percutaneous cholecystostomy is a procedure with a relatively low mortality and high technical and clinical success rate (> 90%),–C is OK
even in toxic conditions ,post op cases, or some one incritical condition cholecystostomy gives very good relief