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Review Question - QID 210962

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QID 210962 (Type "210962" in App Search)
A 42-year-old woman presents to the emergency department for evaluation of abdominal pain. The pain started last night during dinner and has persisted. This morning, the patient felt very ill and her husband called emergency medical services. She has a medical history of obesity, diabetes, and depression. Her temperature is 104°F (40°C), blood pressure is 90/65 mmHg, pulse is 160/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a very ill-appearing woman. Her skin is jaundiced, and there is scleral icterus. She is in an antalgic position on the stretcher. There is tenderness to palpation over the right upper quadrant. Laboratory values are ordered as seen below. Right upper quadrant ultrasound demonstrates a thickened, distended common bile duct. Hemoglobin: 13 g/dL Hematocrit: 38% Leukocyte count: 22,500 cells/mm^3 with normal differential Platelet count: 257,000/mm^3 Alkaline phosphatase: 355 U/L Bilirubin, total: 11.3 mg/dL Bilirubin, direct: 9.8 mg/dL AST: 42 U/L ALT: 31 U/L The patient is started on antibiotics and IV fluids. Which of the following is the most appropriate next step in management?




CT abdomen pelvis with contrast



Endoscopic retrograde cholangiopancreatography



Exploratory laparotomy



Magnetic resonance cholangiopancreatography



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This patient with fever, jaundice, and right upper quadrant pain likely has developed ascending cholangitis. After fluid resuscitation and initiation of broad spectrum antibiotics, the most appropriate next step in management is endoscopic retrograde cholangiopancreatography.

Ascending cholangitis occurs due to obstruction of the common bile duct, most commonly secondary to cholelithiasis. As the duct becomes obstructed and is unable to drain, infection develops and travels up the common bile duct to the gallbladder and liver. Classically, patients present with right upper quadrant abdominal pain, fever, jaundice, altered mental status, and hypotension (Reynold pentad). Patients will typically have a profound leukocytosis, an elevated direct bilirubin and alkaline phosphatase, and mildly elevated liver enzymes. Ultrasound of the abdomen will demonstrate biliary dilation and gallbladder thickening. The best initial step in management is IV fluids, antibiotics, and emergency decompression of the common bile duct with endoscopic retrograde cholangiopancreatography (ERCP).

An. et al review acute cholangitis. They discuss pathophysiology, clinical manifestations, and strategies for management. They recommend that patients with suspected acute cholangitis undergo ERCP.

Incorrect Answers:
Answer 1: Emergency cholecystectomy would be indicated for emphysematous cholecystitis, which may present similarly. This patient's imaging demonstrating a dilated common bile duct suggests ascending cholangitis, which is treated with ERCP. Cholecystectomy would eventually be indicated.

Answer 1: CT abdomen pelvis with contrast is generally less sensitive for biliary pathology than ultrasound imaging. In addition, this patient's clinical presentation, lab, and imaging findings suggest the diagnosis of ascending cholangitis. The addition of CT imaging is not likely to be beneficial and would delay definitive management.

Answer 4: Exploratory laparotomy would be indicated if a perforated viscus or peritonitis was suspected. While this patient is critically ill, her exam findings do not suggest peritonitis. Ascending cholangitis is not managed with exploratory laparotomy.

Answer 5: Magnetic resonance cholangiopancreatography is used to better characterize pathology affecting the pancreas and biliary tree. This patient is critically ill secondary to ascending cholangitis, warranting immediate intervention with ERCP (which would be delayed if MRCP was obtained).

Bullet Summary:
Ascending cholangitis is managed with ultrasound, broad-spectrum antibiotics, and emergent decompression of the biliary tree via endoscopic retrograde cholangiopancreatography.

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