A 54-year-old woman comes to the emergency department due to 12 hours of constant upper abdominal discomfort, nausea, and vomiting. The patient had a large dinner, went to bed feeling well, and was awakened by severe pain. In the past year, she has had brief similar episodes, but the pain was never this persistent. She has had no diarrhea or dysuria. Medical history includes gastroesophageal reflux, hyperlipidemia, and type 2 diabetes mellitus. The patient does not use alcohol, tobacco, or illicit drugs. Temperature is 38.3 C (100.9 F), blood pressure is 140/90 mm Hg, pulse is 110/min, and respirations are 20/min. BMI is 33.2 kg/m². The lungs are clear to auscultation and heart sounds are normal. Abdominal examination reveals moderate tenderness in the right upper quadrant with voluntary guarding. There is no rebound tenderness. Laboratory results are as follows: Ultrasound of the abdomen reveals several small gallstones without gallbladder wall edema or sonographic Murphy sign. The common bile duct is not enlarged. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: This woman with persistent right upper quadrant pain, fever, and leukocytosis likely has acute calculous cholecystitis. Acute calculous cholecystitis occurs when a gallstone obstructs the cystic duct and results in gallbladder wall inflammation. Manifestations typically include persistent abdominal pain, nausea, vomiting, fever, and leukocytosis. Liver function tests, bilirubin, and alkaline phosphatase usually remain within normal limits because the obstruction is limited to the gallbladder. The diagnosis of acute calculous cholecystitis is typically confirmed when right upper quadrant ultrasound reveals choleliths with gallbladder wall thickening or sonographic Murphy sign (increased pain when the sonographic transducer compresses the gallbladder). If ultrasound is negative or inconclusive, patients should receive a hepatobiliary iminodiacetic acid (HIDA) scan (cholescintigraphy). This nuclear medicine test has a sensitivity and specificity of >90% for acute cholecystitis. (Choice A) Patients with acute cholecystitis usually require an emergency laparoscopic cholecystectomy (ideally within 72 hours of symptom onset). However, the diagnosis should be confirmed with a HIDA scan prior to undergoing an invasive abdominal operation. (Choice B) Patients with biliary colic typically have transient (<6 hours) right upper quadrant pain, nausea, and vomiting. Biliary colic is typically managed with as-needed pain control and elective cholecystectomy. This patient with persistent abdominal pain, fever, and leukocytosis is more likely to have acute cholecystitis; she requires a HIDA scan. (Choice C) A contrast-enhanced CT scan of the abdomen can detect other causes of abdominal pain or evaluate for complications of acute cholecystitis (eg, gallbladder perforation). However, CT scan of the abdomen has worse sensitivity and specificity for the diagnosis of acute cholecystitis compared to ultrasound and HIDA scan. (Choice E) Endoscopic retrograde cholangiopancreatography is typically used when choledocholithiasis is suspected. Choledocholithiasis also manifests with abdominal pain, fever, and leukocytosis; however, patients usually have common bile duct dilation on ultrasound and elevated bilirubin and alkaline phosphatase levels. Educational objective: Acute cholecystitis typically presents with persistent right upper quadrant pain, fever, nausea, vomiting, and leukocytosis. Diagnosis is confirmed when ultrasound reveals choleliths with gallbladder wall thickening or sonographic Murphy sign. If ultrasound is negative or inconclusive, a hepatobiliary iminodiacetic acid (HIDA) scan is the next diagnostic test of choice and is usually confirmatory. References: Does this patient have acute cholecystitis? (http://www.ncbi.nlm.nih.gov/pubmed/12503981) Diagnosis of acute cholecystitis: sensitivity of sonography, cholescintigraphy, and combined sonography-cholescintigraphy. (http://www.ncbi.nlm.nih.gov/pubmed/11768676)

A 54-Year-Old Woman Comes to the Emergency Department Due to 12