An 82-year-old man is brought to the emergency department due to fever and confusion. Yesterday, he experienced abdominal pain, nausea, vomiting, and rigors in the nursing home where he lives. Earlier today, he was found to be lethargic. Medical history includes hypercholesterolemia, type 2 diabetes mellitus, and Alzheimer dementia. The patient quit smoking 30 years ago and does not drink alcohol. Temperature is 39.1 C (102.4 F), blood pressure is 105/55 mm Hg, pulse is 110/min, and respirations are 20/min. He is lethargic but arousable to strong stimuli. On examination, the mucous membranes are dry. Scleral icterus is present. No cardiac murmurs are heard. The lungs are clear to auscultation. There is marked tenderness in the right upper quadrant and epigastrium but no distension, rebound, or guarding. Laboratory results are as follows: An abdominal ultrasound reveals multiple gallstones and a dilated common bile duct. The gallbladder wall is not thickened. In addition to aggressive intravenous hydration and antibiotics, which of the following is the best next step in management of this patient?

Question

An 82-year-old man is brought to the emergency department due to fever and confusion.  Yesterday, he experienced abdominal pain, nausea, vomiting, and rigors in the nursing home where he lives.  Earlier today, he was found to be lethargic.  Medical history includes hypercholesterolemia, type 2 diabetes mellitus, and Alzheimer dementia.  The patient quit smoking 30 years ago and does not drink alcohol.  Temperature is 39.1 C (102.4 F), blood pressure is 105/55 mm Hg, pulse is 110/min, and respirations are 20/min.  He is lethargic but arousable to strong stimuli.  On examination, the mucous membranes are dry.  Scleral icterus is present.  No cardiac murmurs are heard.  The lungs are clear to auscultation.  There is marked tenderness in the right upper quadrant and epigastrium but no distension, rebound, or guarding.  Laboratory results are as follows:  An abdominal ultrasound reveals multiple gallstones and a dilated common bile duct.  The gallbladder wall is not thickened.  In addition to aggressive intravenous hydration and antibiotics, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation suggests gallstone pancreatitis complicated by acute cholangitis. Gallstone pancreatitis develops when a gallstone passes through the biliary tree and obstructs the ampulla or flow from the pancreatic duct, allowing bile to reflux into the pancreas. In addition to the classic manifestations of pancreatitis (eg, abdominal pain, nausea/vomiting, elevated serum lipase or amylase), patients with obstruction of the ampulla may also demonstrate cholestatic liver function studies (eg, elevated bilirubin, alkaline phosphatase, transaminases). If the stone remains in the biliary tract, the resultant bile stasis can allow bacteria to ascend from the duodenum, leading to acute cholangitis. In addition to cholestatic liver function studies (due to stasis and obstruction), the presence of Charcot triad (right upper quadrant pain, jaundice, fevers) suggests the diagnosis, and altered mental status and hypotension (ie, Reynolds pentad) indicate particularly severe disease. Common bile duct dilation (as seen in this patient) or choledocholithiasis on a right upper quadrant ultrasound further support the diagnosis. Management includes aggressive intravenous hydration and antibiotics. Endoscopic retrograde cholangiopancreatography (ERCP) is indicated to relieve the biliary obstruction, during which a sphincterotomy, stone extraction, and/or biliary stent placement can be performed. (Choice A) Although a CT scan can help diagnose pancreatitis, the combination of acute abdominal pain and elevated serum lipase is sufficient for diagnosis. In addition, a CT scan is less sensitive than an ultrasound for detecting changes associated with cholangitis (eg, common bile duct dilation) and may miss gallstones, which are frequently radiolucent. (Choices B and D) A HIDA scan is used to diagnose cholecystitis in patients with equivocal ultrasound findings; however, in addition to fevers and right upper quadrant pain, cholecystitis results in gallbladder wall thickening and edema visible on ultrasound, whereas biliary dilation suggests cholangitis. An elective cholecystectomy to prevent further complications of gallstone disease should be deferred until after the current complications have resolved. (Choice E) The presence of cholangitis requires ERCP to relieve the biliary obstruction; failure to remove the obstructive gallstone may result in septic shock and death. Educational objective: Acute cholangitis should be suspected in a patient with gallstone pancreatitis who also has fevers, right upper quadrant pain, jaundice, altered mental status, and hypotension. Endoscopic retrograde cholangiopancreatography is required to relieve the biliary obstruction and prevent serious infectious complications.

An 82-Year-Old Man Is Brought to the Emergency Department Due