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A 76-year-old male is brought in by fire rescue to the emergency department. His history is notable for obesity, hypertension, and metabolic syndrome. His pulse is 115/min, blood pressure is 90/60 mmHg, respirations are 20/min, and SpO2 is 98%. The patient's sclera are notably icteric. He is disoriented and becomes agitated when his abdomen is palpated in the right upper quadrant. The patient is admitted to the intensive care unit for management. After initial stabilization with IV fluids and broad spectrum antibiotics, an MRCP is obtained after abdominal ultrasound demonstrates gallstones (shown in Figure A). Overnight, the patient becomes hemodynamically unstable and is started on vasopressor support. What is the most appropriate next step in management?
Rifaximin and lactulose
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A 42-year-old female presents to the emergency department with two days of severe abdominal pain and fever. The patient has a history of gallstones, for which she was scheduled to have a cholecystectomy in two weeks. On physical exam, her abdomen is tender to palpation over the epigastrium, without rebound or guarding. The patient is noticeably jaundiced. Laboratory evaluation is notable for a leukocytosis and a total bilirubin of 6.4 mg/dL. What is the diagnosis in this patient?
Primary sclerosing cholangitis
A 40-year-old female visits the emergency department with right upper quadrant pain and fever of 2-hours duration. She denies alcohol, cigarette, and drug use and reports no other medical problems. Body mass index is 30 kg/m^2. Her temperature is 38.5 degrees Celsius (101.3 degrees Fahrenheit), blood pressure is 130/80 mm Hg, pulse is 90/min, and respirations are 18/min. Jaundice is present in the sclera and at the base of the tongue. The abdomen is tender in the right upper quadrant. Liver function test (LFTs) reveal elevated direct and total bilirubin and alkaline phosphatase of 500 U/L. IV Ampicillin-gentamicin is administered, fluid resuscitation is initiated, and over 24 hours the patient’s fever improves. Which of the following is the next step in the management of this patient:
Elective laparoscopic cholecystectomy
Urgent open cholecystectomy
Endoscopic retrograde cholangiopancreatography (ERCP)
Administer bile acids
Extracorporeal shock wave lithotripsy