A 75-year-old woman comes to the emergency department due to fever, chills, abdominal pain, nausea, and vomiting for the past 2 days. She did not eat anything unusual, and no one else at her home is sick. The patient has no diarrhea, dysuria, or urinary frequency. Medical issues include type 2 diabetes mellitus, hypertension, obstructive sleep apnea, and coronary artery disease. Temperature is 38.9 C (102 F), blood pressure is 130/80 mm Hg, pulse is 104/min, and respirations are 18/min. Oxygen saturation is 94% on room air. BMI is 32 kg/m². On physical examination, the patient appears acutely unwell. The oropharynx has dry mucous membranes, and dentition is poor. Cardiopulmonary examination shows normal lung and heart sounds. Abdomen is mildly distended. There is marked tenderness over the epigastrium and right upper quadrant with guarding. Bowel sounds are decreased. The extremities have no cyanosis or edema. Laboratory studies are as follows. Abdominal ultrasonogram reveals thickening of the gallbladder wall, pericholecystic fluid, and multiple hyperechoic calculi. Air is noted within the gallbladder wall, and the common bile duct is not dilated. Intravenous fluids, insulin, analgesics, and broad-spectrum antibiotics are initiated. Which of the following additional intervention is most appropriate in the management of this patient?

Question

Quizplus · Accepted Answer

11ec25c8_d8e3_fec8_bc81_bdc1d0d8b00e_MD0003_00 This patient has emphysematous cholecystitis (EC), characterized by fever, right upper quadrant (RUQ) pain, and gas in the gallbladder wall or surrounding tissue. Unlike uncomplicated acute cholecystitis, EC is a surgical emergency and warrants immediate intervention. In addition to emergency cholecystectomy, management involves broad-spectrum antibiotics (eg, piperacillin-tazobactam, ertapenem) and bile culture. EC occurs when gas-forming organisms such as Clostridium infect damaged or ischemic tissue in the gallbladder wall, with bacterial exotoxins resulting in hemolysis, tissue necrosis, and septic shock; if untreated, EC progresses to gangrenous cholecystitis and gallbladder perforation in most patients. Risk factors include relative immunosuppression (eg, age >50, diabetes mellitus) and vascular disease (eg, compromised cystic artery blood supply, atherosclerosis). In addition to pain and guarding, crepitus in the RUQ may occasionally be present. Typical laboratory findings include leukocytosis with left shift and small elevations in aminotransferases. With clostridial infection, a mild to moderate unconjugated hyperbilirubinemia can occur secondary to hemolysis, as is likely in this patient. Imaging may demonstrate pneumobilia (air within the hepatobiliary system), air-fluid levels in the gallbladder, and gas within the gallbladder wall or surrounding tissue. Unlike other forms of acute cholecystitis, ultrasound is less sensitive due to the modality's poor visualization of air-filled structures, and extensive gas in the gallbladder wall may be falsely interpreted as being due to bowel loops. CT imaging is preferred due to the improved ability to delineate air-filled structures. CT imaging (Choices A, B, and E) Cholecystectomy prior to discharge and ideally within 72 hours is the standard of care in low-risk patients with acute (nonemphysematous) cholecystitis. In high-risk patients (eg, severe systemic illness) with cholecystitis, cholecystectomy may be delayed until after recovery, with patients managed with antibiotic therapy and possible gallbladder drainage. Some patients with EC who cannot tolerate surgery undergo gallbladder (eg, percutaneous) drainage only. (Choice D) Endoscopic retrograde cholangiopancreatography (with stone extraction/stent placement) is recommended for acute cholangitis, which is due to ascending biliary tract infection (eg, due to biliary obstruction) and may cause fever, RUQ pain, and jaundice (Charcot triad); if endoscopy is unsuccessful, percutaneous drainage may facilitate biliary drainage. However, acute cholangitis does not usually cause gas within the gallbladder wall and would be accompanied by common bile duct dilation and a more marked hyperbilirubinemia that is typically conjugated (due to biliary stasis). Educational objective: Emphysematous cholecystitis is characterized by fever, right upper quadrant pain, and gas in the gallbladder wall, surrounding tissue, or hepatobiliary system. It occurs when gas-forming organisms such as Clostridium infect damaged or ischemic tissue but, unlike uncomplicated acute cholecystis, it is a surgical emergency and warrants immediate cholecystectomy. References: Emphysematous cholecystitis. (http://www.ncbi.nlm.nih.gov/pubmed/22007119) Emphysematous cholecystitis: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/18687128)

A 75-Year-Old Woman Comes to the Emergency Department Due to Fever