Snapshot A 40-year-old obese woman presents to the emergency room for pain in her right upper quadrant of her abdomen. She reports that she has had similar pain on and off for the past few weeks, but this time the pain has persisted for over an hour. She also reports nausea, vomiting, and loss of appetite. On physical exam, she has right upper quadrant pain and inspiratory arrest with deep palpation of the area. An ultrasound of that area reveals distended gallbladder with thickened gallbladder wall and gallstones. She is admitted for further management and the general surgery team is consulted for possible surgery within the next 72 hours. Introduction Clinical definition acute inflammation of the gallbladder, often in the setting of gallstones or biliary sludge acalculous cholecystitis etiology gallbladder stasis hypoperfusion infection often seen in very ill patients associated with high mortality calculous cholecystitis etiology gallstone impaction resulting in inflammation more common Epidemiology Demographics female > male adults Risk factors gallstones F's Fat Female Forty Flatulent Fertile hormone replacement therapy obesity hypertriglyceridemia etiology EEEK bugs E. coli Enterobacter Enterococcus Klebsiella ETIOLOGY Pathogenesis blockage of cystic duct by gallstones can lead to distention of gallbladder, inflammation, and infection Presentation Symptoms systemic symptoms fevers chills nausea and vomiting anorexia right upper quadrant pain may radiate to shoulder Physical exam inspection jaundice typically not seen palpation right upper quadrant tenderness to palpation peritoneal signs may indicate perforation gallbladder may be palpable tests Murphy sign arrest of inspiration with palpation of right upper quadrant Boas sign hyperesthesia to light touch in right upper quadrant or infrascapular area imaging Right upper quadrant ultrasound best initial imaging findings stones biliary sludge thickened gallbladder wall ultrasonic Murphy sign Cholescintigraphy (HIDA scan) indication ultrasound findings are equivocal but clinical suspicion is strong findings lack of gallbladder visualization = obstruction Computed tomography of abdomen and pelvis indication to rule out other abdominal pathologies findings gallbladder distention thickened gall bladder wall pericholecystic fat stranding abscesses Studies Diagnostic testing studies ↑ or normal alkaline phosphatase ↑ or normal bilirubin ↑ or normal white blood cell count Differential Acute pancreatitis distinguishing factor usually has elevated lipase and epigastric tenderness may be associated with gallstones DIAGNOSIS Diagnostic criteria local inflammation Murphy sign right upper quadrant tenderness systemic inflammation fever ↑ white blood cell count imaging cholecystitis Treatment First-line supportive care intravenous fluids electrolyte repletion analgesia intravenous antibiotics non-emergent cholecystectomy indication usually done within 72 hours emergent cholecystectomy indication generalized peritonitis perforated cholecystitis or gangrenous cholecystitis Second-line percutaneous drainage indication medically unstable for cholecystectomy Complications Ascending cholangitis Gallbladder perforation Post cholecystectomy syndrome occurs after a cholecystectomy presents with right upper quadrant pain increased AST/ALT and alkaline phosphatase management ultrasound endoscopic retrograde cholangiopancreatography (ERCP)
QUESTIONS 1 of 7 1 2 3 4 5 6 7 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M3.GI.16.35) A 48-year-old female presents to the emergency department with fevers, and worsening abdominal pain for 24 hours. Exam demonstrates an overweight female in distress. Abdominal exam is notable for tenderness to palpation in the right upper quadrant and a positive ultrasonic (US) murphy's sign. Right upper quadrant ultrasound is shown in Figure A. Vital signs are as follows: T 102.1 F HR 84 BP 135/92 RR 14 O2 Sat 97%. Lab studies demonstrate leukocytosis. What's the next best step in management? QID: 103058 FIGURES: A Type & Select Correct Answer 1 IV fluid hydration, analgesics, NPO, Interval cholecystectomy after 7 days antibiotic therapy 9% (1/11) 2 IV fluid hydration, analgesics, NPO, Open cholecystectomy 0% (0/11) 3 IV fluid hydration, analgesics, NPO, Laparoscopic cholecystectomy 82% (9/11) 4 IV fluid hydration, analgesics, NPO, Hida Scan 0% (0/11) 5 IV fluid hydration, analgesics, NPO, Endoscopic retrograde cholangiopancreatography (ERCP) 9% (1/11) M 11 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (M2.GI.15.30) A 70-year-old male presents to the emergency department with fever and productive cough that has progressed rapidly over the past day. On exam, he is very ill appearing and his vitals demonstrate T: 39 deg C, HR: 95 bpm, BP: 80/40 mmHg, RR: 15, SaO2: 93%. A CBC is obtained which demonstrates a white blood cell count (WBC) of 14,000. A chest radiograph is obtained which is demonstrated in Figure A. The patient is subsequently diagnosed with severe sepsis secondary to pneumonia and is transferred to the ICU after intubation, appropriate antibiotic therapy, and resuscitation measures are initiated. The patient improves steadily over the subsequent days in the ICU with improving vitals and decreasing WBC. However, on hospital day 4 he develops a fever to 41 deg C, and his WBC elevates to 16,000. On exam, he appears to withdraw in pain when his abdomen is palpated. Liver function tests and amylase/lipase are ordered and shown to be within normal limits. An abdominal ultrasound is obtained which is demonstrated in Figure B. What is the most likely cause of this patient's current presentation? QID: 104821 FIGURES: A B Type & Select Correct Answer 1 Cholelithiasis 0% (0/32) 2 Cholangitis 6% (2/32) 3 Acute calculous cholecystitis 0% (0/32) 4 Acute acalculous cholecystitis 91% (29/32) 5 Acute pancreatitis 0% (0/32) M 6 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
All Videos (0) Gastrointestinal | Acute Cholecystitis Gastrointestinal - Acute Cholecystitis Listen Now 14:29 min 11/19/2021 82 plays 5.0 (1)