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 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 Studies Diagnostic testing 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 ↑ or normal alkaline phosphatase ↑ or normal bilirubin ↑ or normal white blood cell count Diagnostic criteria local inflammation Murphy sign right upper quadrant tenderness systemic inflammation fever ↑ white blood cell count imaging cholecystitis Differential Acute pancreatitis distinguishing factor usually has elevated lipase and epigastric tenderness may be associated with gallstones 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 6 1 2 3 4 5 6 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + 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 You have 100% on this question. Just skip this one for now. Take This Question Anyway (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? Review Topic | Tested Concept QID: 103058 FIGURES: A Type & Select Correct Answer 1 IV fluid hydration, analgesics, NPO, Interval cholecystectomy after 7 days antibiotic therapy 25% (1/4) 2 IV fluid hydration, analgesics, NPO, Open cholecystectomy 0% (0/4) 3 IV fluid hydration, analgesics, NPO, Laparoscopic cholecystectomy 50% (2/4) 4 IV fluid hydration, analgesics, NPO, Hida Scan 0% (0/4) 5 IV fluid hydration, analgesics, NPO, Endoscopic retrograde cholangiopancreatography (ERCP) 25% (1/4) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (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? Review Topic | Tested Concept QID: 104821 FIGURES: A B Type & Select Correct Answer 1 Cholelithiasis 0% (0/24) 2 Cholangitis 8% (2/24) 3 Acute calculous cholecystitis 0% (0/24) 4 Acute acalculous cholecystitis 88% (21/24) 5 Acute pancreatitis 0% (0/24) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4