Gallstones And Biliary Tract Disease! Trivia Quiz

1.

A 58-year-old man with altered mental status is brought to the emergency department by the emergency medical service. No history can be obtained. On physical examination, the patient is found to have fever, hypotension, jaundice, and right upper quadrant pain with guarding. Laboratory evaluation reveals leukocytosis, an alkaline phosphatase level of 180 U/L, and a bilirubin level of 5 mg/dl. The patient is diagnosed as having cholangitis.

For this patient, which of the following imaging modalities has both diagnostic and therapeutic utility?

Endoscopic ultrasound (EUS)

Abdominal ultrasound

Magnetic resonance cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP)

Key Concept/Objective: To know that endoscopic retrograde cholangiopancreatography is both a diagnostic and therapeutic modality ERCP allows radiographic visualization of the biliary tree and the option of therapeutic intervention. EUS has greater sensitivity and specificity than ERCP in the detection of common bile duct stones but lacks the therapeutic option available with ERCP. Therefore, ERCP is the test of choice if common bile stones are highly suspected on the basis of history, physical examination, and laboratory and imaging studies. Percutaneous transhepatic cholangiography (PTC) involves accessing the bile ducts via a small needle. The success rate of PTC in patients with dilated ducts is close to 100%; nondilated ducts are entered successfully about 70% of the time. Complication rates for both ERCP and PTC approach 5%. ERCP has replaced PTC as the technique of choice.

Explanation

Key Concept/Objective: To know that endoscopic retrograde cholangiopancreatography is both a diagnostic and therapeutic modality ERCP allows radiographic visualization of the biliary tree and the option of therapeutic intervention. EUS has greater sensitivity and specificity than ERCP in the detection of common bile duct stones but lacks the therapeutic option available with ERCP. Therefore, ERCP is the test of choice if common bile stones are highly suspected on the basis of history, physical examination, and laboratory and imaging studies. Percutaneous transhepatic cholangiography (PTC) involves accessing the bile ducts via a small needle. The success rate of PTC in patients with dilated ducts is close to 100%; nondilated ducts are entered successfully about 70% of the time. Complication rates for both ERCP and PTC approach 5%. ERCP has replaced PTC as the technique of choice.

2. A 40-year-old woman with diabetes and chronic kidney disease present to the clinic for follow-up after an abdominal ultrasound revealed incidental cholelithiasis without inflammation. The ultrasound revealed two stones, which were less than 5 mm in size. The patient's kidneys were normal. The patient denies experiencing abdominal pain, nausea, or vomiting. She has not had cholecystitis in the past. Of the following, which is the best step to take next in the treatment of this patient?

Cholecystectomy

Endoscopic retrograde cholangiopancreatography (ERCP)

Observation

Percutaneous transhepatic cholangiogram

Key Concept/Objective: To understand the management of asymptomatic cholelithiasis Patients who have asymptomatic gallstones should generally be managed conservatively without surgery. Exceptions may be made for patients at increased risk for gallbladder cancer, such as Pima Indians, persons with calcified gallbladders (porcelain gallbladder), patients with very large gallstones (> 3 cm), and patients with an associated gallbladder polyp greater than 10 mm in diameter. In the past, prophylactic cholecystectomy was recommended for diabetic patients who had asymptomatic gallstones; anecdotal reports suggested that such patients did poorly when cholecystectomy was performed as an emergency procedure. However, two well-controlled retrospective studies of patients undergoing surgery for acute cholecystitis, as well as decision analysis, showed that diabetes was not an independent risk factor of operative mortality or serious postoperative complications, and prophylactic cholecystectomy resulted in a shortened life span. Thus, prophylactic cholecystectomy cannot be recommended for patients with diabetes

Explanation

Key Concept/Objective: To understand the management of asymptomatic cholelithiasis Patients who have asymptomatic gallstones should generally be managed conservatively without surgery. Exceptions may be made for patients at increased risk for gallbladder cancer, such as Pima Indians, persons with calcified gallbladders (porcelain gallbladder), patients with very large gallstones (> 3 cm), and patients with an associated gallbladder polyp greater than 10 mm in diameter. In the past, prophylactic cholecystectomy was recommended for diabetic patients who had asymptomatic gallstones; anecdotal reports suggested that such patients did poorly when cholecystectomy was performed as an emergency procedure. However, two well-controlled retrospective studies of patients undergoing surgery for acute cholecystitis, as well as decision analysis, showed that diabetes was not an independent risk factor of operative mortality or serious postoperative complications, and prophylactic cholecystectomy resulted in a shortened life span. Thus, prophylactic cholecystectomy cannot be recommended for patients with diabetes

3.

A 48-year-old African American woman presents to theemergency department with anorexia, nausea, vomiting,and abdominal pain over the last week. The pain wasinitially in the midepigastric area but has shifted to the rightupper quadrant. This most recent episode of pain hasprogressed over the last 5 hours. She has no past medicalhistory, takes no medications, and has never been pregnant.Her temperature is 38.3° C (100.9° F), blood pressureis 135/80 mm Hg, and pulse is 105 beats/min. She isanicteric and has diminished skin turgor. Her abdomen issoft, and she has voluntary guarding and inspiratory arrestwhen palpating the right upper quadrant. Pelvic and rectalexaminations are unremarkable. Her leukocyte count is14,000/cumm with a left shift, direct bilirubin is 2.4 mg/dL,alkaline phosphatase is 250 U/L, and the remainder of herliver function tests, electrolytes, and pancreatic enzymes arewithin normal limits.

Which of the following tests is warranted to confi rm a diagnosis of acute cholecystitis in this patient?

CT of the abdomen and pelvis with intravenous contrast

Transabdominal ultrasonography (TUS)

Plain abdominal x-rays (KUB)

Cholescintigraphy with intravenous injection oftechnetium-99m-labeled hepatoiminodiaceticacid (HIDA)

Key Concept/Objective: To reinforce that HIDA cholescintigraphy is the test of choice for confi rmation of a clinical diagnosis of acute cholecystitis
TUS is the diagnostic procedure of choice for a patientwith suspected gallstones and acute cholecystitis. Ameta-analysis revealed that ultrasonography had asensitivity of 88 to 90% and a specifi city of 97 to 98% forthe diagnosis of gallstones greater than 2 mm in size.Gallbladder ultrasonography should ideally be preceded byan 8-hour fast because gallstones are best visualized in adistended, bile-fi lled gallbladder. In addition to detectinggallstones, ultrasonography can be used to identify othercauses of right upper quadrant pain, such as hepatic abscessor malignancy, and it may reveal biliary duct obstruction.However, specifi c evidence of acute cholecystitis (i.e., thepresence of pericholecystic fl uid, edema of the gallbladderwall, or both) is found infrequently. Occasionally, aso-called sonographic Murphy sign is elicited when theultrasound probe is positioned below the right costalmargin. Cholescintigraphy is the best method of confi rmingthe clinical diagnosis of acute cholecystitis. This procedure,which takes only 60 to 90 minutes, involves the intravenousinjection of technetium-99m-labeled HIDA (lidofenin),which is selectively excreted into the biliary tree and entersthe gallbladder. In the presence of acute cholecystitis,radiolabeled material enters the common bile duct andduodenum but not the gallbladder. A meta-analysissuggests that radionuclide scanning is the most accuratemethod of diagnosing acute cholecystitis. Occasionally, thescan gives false positive results in patients who havealcoholic liver disease, in those who are fasting, or in thosereceiving total parenteral nutrition; however, false negativeresults are rare. Radionuclide scanning may not be usefulfor patients with deep jaundice, because the labeled agentfails to enter the biliary tree.

Explanation

Key Concept/Objective: To reinforce that HIDA cholescintigraphy is the test of choice for confi rmation of a clinical diagnosis of acute cholecystitis
TUS is the diagnostic procedure of choice for a patientwith suspected gallstones and acute cholecystitis. Ameta-analysis revealed that ultrasonography had asensitivity of 88 to 90% and a specifi city of 97 to 98% forthe diagnosis of gallstones greater than 2 mm in size.Gallbladder ultrasonography should ideally be preceded byan 8-hour fast because gallstones are best visualized in adistended, bile-fi lled gallbladder. In addition to detectinggallstones, ultrasonography can be used to identify othercauses of right upper quadrant pain, such as hepatic abscessor malignancy, and it may reveal biliary duct obstruction.However, specifi c evidence of acute cholecystitis (i.e., thepresence of pericholecystic fl uid, edema of the gallbladderwall, or both) is found infrequently. Occasionally, aso-called sonographic Murphy sign is elicited when theultrasound probe is positioned below the right costalmargin. Cholescintigraphy is the best method of confi rmingthe clinical diagnosis of acute cholecystitis. This procedure,which takes only 60 to 90 minutes, involves the intravenousinjection of technetium-99m-labeled HIDA (lidofenin),which is selectively excreted into the biliary tree and entersthe gallbladder. In the presence of acute cholecystitis,radiolabeled material enters the common bile duct andduodenum but not the gallbladder. A meta-analysissuggests that radionuclide scanning is the most accuratemethod of diagnosing acute cholecystitis. Occasionally, thescan gives false positive results in patients who havealcoholic liver disease, in those who are fasting, or in thosereceiving total parenteral nutrition; however, false negativeresults are rare. Radionuclide scanning may not be usefulfor patients with deep jaundice, because the labeled agentfails to enter the biliary tree.

4.

A 43-year-old female presents to clinic with postprandial nausea and vomiting. Occasionally, she develops midepigastric pain that radiates to the right shoulder. These painful episodes last between 4 and 6 hours and resolve spontaneously. She does not have any pruritus, jaundice, weight changes, or changes in stool caliber. She has a history of cholecystitis treated by cholecystectomy 3 years previously, hypertension, and gastroesophageal refl ux disease. She currently takes omeprazole 20 mg daily and lisinopril 10 mg daily. She does not smoke or drink alcoholic beverages. On physical examination, her abdomen is soft and nondistended, and there is diffuse tenderness to palpation. There are no masses or organomegaly. Hemoccult is negative. Her leukocyte count is 6,000 with a normal differential, hemoglobin is 13 g/dL, total bilirubin is 1.8 mg/dL, direct bilirubin is 1.0 mg/dL, alkaline phosphatase is 170 U/L, AST is 110 U/L, ALT is 88 U/L, and serum creatinine is 0.6 mg/dL. CT of the abdomen with intravenous contrast reveals a normalappearing liver, pancreas, and gallbladder fossa but dilation of the common bile duct without visualization of biliary tract stones.

What is the next best step in diagnosis of sphincter of Oddi dysfunction (SOD) in this patient?

Endoscopic retrograde cholangiopancreatography (ERCP with SOD manometry

Neostigmine provocation test

Secretin stimulated magnetic resonance cholangiopancreatography (MRCP) with manometry

Empiric treatment with long-acting oral nitrates

Key Concept/Objective: To review that the gold standard for diagnosis of SOD is ERCP with manometry SOD is a benign condition of intermittent or permanent obstruction of biliary drainage, pancreatic drainage, or both that is caused by either a stenosis or smooth muscle dysfunction of the sphincter muscle. Biliary SOD is usually seen in women in their fourth to sixth decades of life. The symptoms arise typically after cholecystectomy, although SOD may occur in patients with an intact gallbladder. The clinical presentation of biliary SOD is episodic abdominal pain in the epigastric or right upper quadrant region that may radiate to the back or shoulders. It may be associated with nausea or vomiting that worsens with eating. Laboratory tests may reveal abnormalities in liver function. Right upper quadrant sonography and CT may reveal a dilated common bile duct. ERCP with SOD manometry is the gold standard for the diagnosis of SOD. A basal sphincter pressure of greater than 40 mm Hg is abnormal and indicative of SOD. Other tests that are noninvasive and less reliable may also indicate the presence of SOD; such tests include a provocation test using morphine (or neostigmine), which produces biliary pain and serum aminotransferase elevation; ultrasound evaluation of dilation and emptying of the common bile duct after secretin stimulation; and the scintigraphic evaluation of the kinetics of ductal emptying. Secretin-stimulated MRCP with manometry may be useful in selecting patients who would most benefit from endoscopic therapy.

Explanation

Key Concept/Objective: To review that the gold standard for diagnosis of SOD is ERCP with manometry SOD is a benign condition of intermittent or permanent obstruction of biliary drainage, pancreatic drainage, or both that is caused by either a stenosis or smooth muscle dysfunction of the sphincter muscle. Biliary SOD is usually seen in women in their fourth to sixth decades of life. The symptoms arise typically after cholecystectomy, although SOD may occur in patients with an intact gallbladder. The clinical presentation of biliary SOD is episodic abdominal pain in the epigastric or right upper quadrant region that may radiate to the back or shoulders. It may be associated with nausea or vomiting that worsens with eating. Laboratory tests may reveal abnormalities in liver function. Right upper quadrant sonography and CT may reveal a dilated common bile duct. ERCP with SOD manometry is the gold standard for the diagnosis of SOD. A basal sphincter pressure of greater than 40 mm Hg is abnormal and indicative of SOD. Other tests that are noninvasive and less reliable may also indicate the presence of SOD; such tests include a provocation test using morphine (or neostigmine), which produces biliary pain and serum aminotransferase elevation; ultrasound evaluation of dilation and emptying of the common bile duct after secretin stimulation; and the scintigraphic evaluation of the kinetics of ductal emptying. Secretin-stimulated MRCP with manometry may be useful in selecting patients who would most benefit from endoscopic therapy.

5.

A 54-year-old man with diabetes and peripheral vascular disease presents to the emergency department with complaints of right upper quadrant abdominal pain of 2 days' duration. On physical examination, the patient appears ill. He has hypotension, fever, and right upper quadrant pain. Laboratory evaluation reveals leukocytosis and a bilirubin level of 3.0 mg/dl. In addition, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels are three times the upper limit of normal. Ultrasound reveals gas in the gallbladder. You make a diagnosis of emphysematous cholecystitis.

Which of the following is the most likely infectious agent in this patient?

Staphylococcus aureus

Cytomegalovirus

Cryptosporidium

Clostridium perfringens

Key Concept/Objective: To know which bacteria are associated with emphysematous cholecystitis
Emphysematous cholecystitis, which is associated with a higher morbidity than uncomplicated acute cholecystitis, is usually caused by gas-forming bacteria, such as C. perfringens and other clostridia, Escherichia coli, or anaerobic streptococci. Patients who have such infections are often very ill, and 20% also have diabetes or are compromised by coexisting conditions. Emphysematous cholecystitis occurs three times more often in men than in women. Many cases of this type of cholecystitis are not associated with cholelithiasis. A plain abdominal x-ray, ultrasound, or CT scan frequently reveals gas within the gallbladder.

Explanation

Key Concept/Objective: To know which bacteria are associated with emphysematous cholecystitis
Emphysematous cholecystitis, which is associated with a higher morbidity than uncomplicated acute cholecystitis, is usually caused by gas-forming bacteria, such as C. perfringens and other clostridia, Escherichia coli, or anaerobic streptococci. Patients who have such infections are often very ill, and 20% also have diabetes or are compromised by coexisting conditions. Emphysematous cholecystitis occurs three times more often in men than in women. Many cases of this type of cholecystitis are not associated with cholelithiasis. A plain abdominal x-ray, ultrasound, or CT scan frequently reveals gas within the gallbladder.

6.

A 52-year-old obese female patient presents to clinic withcomplaints of heartburn, bloating, and mild postprandialmidepigastric fullness. She has painful episodes associatedwith eating two to three times per month. Her past medicalhistory is signifi cant for cholelithiasis, polycystic ovaries,and depression. She is currently only taking acetaminophenon an as-needed basis for her symptoms. She is afebrile,and her physical examination is signifi cant for an obese, softabdomen without organomegaly, masses, or tenderness.Pelvic and rectal examinations are normal. An abdominal x-ray (KUB) shows a normal bowel gas pattern and acalcifi ed gallbladder. Serum electrolytes, creatinine, liverfunction tests, lipase, and a complete blood count are allwithin normal limits. A diagnosis of chronic cholecystitis ismade.

In addition to obtaining a transabdominal sonogram, what is the treatment of choice to reduce symptoms for this patient?

Elective laparoscopic cholecystectomy

Endoscopic stent placement

Observation

Addition of ibuprofen 800 mg as needed for her symptoms

Key Concept/Objective: To recall that cholecystectomy is the treatment of choice for chronic cholecystitis Elective cholecystectomy is indicated for patients who have symptomatic gallstones and chronic cholecystitis. Recurrent pain is to be expected in these patients if cholecystectomy is not performed. As many as 50% of patients with symptomatic gallstones who do not undergo cholecystectomy experience serious complications within 20 years of the initial onset of symptoms. It is occasionally diffi cult to determine whether abdominal symptoms are secondary to documented gallbladder disease. A history of typical recurrent pain makes this determination easier. In certain cases, elective cholecystectomy is performed as a last diagnostic procedure when a thorough search for other causes of abdominal symptoms has proved negative. All too often, the symptoms recur postoperatively.

Explanation

Key Concept/Objective: To recall that cholecystectomy is the treatment of choice for chronic cholecystitis Elective cholecystectomy is indicated for patients who have symptomatic gallstones and chronic cholecystitis. Recurrent pain is to be expected in these patients if cholecystectomy is not performed. As many as 50% of patients with symptomatic gallstones who do not undergo cholecystectomy experience serious complications within 20 years of the initial onset of symptoms. It is occasionally diffi cult to determine whether abdominal symptoms are secondary to documented gallbladder disease. A history of typical recurrent pain makes this determination easier. In certain cases, elective cholecystectomy is performed as a last diagnostic procedure when a thorough search for other causes of abdominal symptoms has proved negative. All too often, the symptoms recur postoperatively.

7.

A 68-year-old diabetic man presents to clinic to follow up a recent sonogram. He has a history of an infrarenal abdominal aortic aneurysm (AAA) and underwent recent screening. A total abdominal sonogram shows an infrarenal AAA with a maximal diameter of 3.3 cm and no evidence of dissection. Incidentally, several cholelithiases were noted within a nondistended gallbladder. He has no abdominal pain, nausea, vomiting, bloating, jaundice, or pruritus.

What is the best management for this patient's biliary disease?

Initiation of ursodeoxycholic acid with meals

Observation

Referral for elective cholecystectomy

Cholescintigraphy with intravenous injection of a technetium-99m-labeled HIDA scan

Key Concept/Objective: To reinforce that conservative therapy without surgery is recommended for diabetic patients with asymptomatic cholelithiasis Patients who have asymptomatic gallstones should generally be managed conservatively without surgery. Exceptions may be made for patients at increased risk for gallbladder cancer, such as Pima Indians, persons with calcifi ed gallbladders (porcelain gallbladder), patients with very large gallstones (> 3 cm), and patients with an associated gallbladder polyp greater than 10 mm in diameter. In the past, prophylactic cholecystectomy was recommended for diabetic patients who had asymptomatic gallstones; anecdotal reports suggested that such patients did poorly when cholecystectomy was performed as an emergency procedure. However, two well-controlled retrospective studies of patients undergoing surgery for acute cholecystitis, as well as a decision analysis, showed that diabetes was not an independent risk factor for operative mortality or serious postoperative complications, and prophylactic cholecystectomy resulted in a shortened life span. Thus, prophylactic cholecystectomy cannot be recommended for patients with diabetes.

Explanation

Key Concept/Objective: To reinforce that conservative therapy without surgery is recommended for diabetic patients with asymptomatic cholelithiasis Patients who have asymptomatic gallstones should generally be managed conservatively without surgery. Exceptions may be made for patients at increased risk for gallbladder cancer, such as Pima Indians, persons with calcifi ed gallbladders (porcelain gallbladder), patients with very large gallstones (> 3 cm), and patients with an associated gallbladder polyp greater than 10 mm in diameter. In the past, prophylactic cholecystectomy was recommended for diabetic patients who had asymptomatic gallstones; anecdotal reports suggested that such patients did poorly when cholecystectomy was performed as an emergency procedure. However, two well-controlled retrospective studies of patients undergoing surgery for acute cholecystitis, as well as a decision analysis, showed that diabetes was not an independent risk factor for operative mortality or serious postoperative complications, and prophylactic cholecystectomy resulted in a shortened life span. Thus, prophylactic cholecystectomy cannot be recommended for patients with diabetes.

8.

A 60-year-old woman with diabetes, severe congestive heart failure, and emphysema presented to clinic complaining of occasional right upper quadrant pain, flatulence, and heartburn. She had been experiencing these symptoms for a period of 1 year. At the time, her physical examination was normal, as was her laboratory evaluation. After undergoing an abdominal ultrasound, she was diagnosed as having chronic cholecystitis, with gallbladder stones and a thickened gallbladder wall. She was referred to surgery. However, the surgeon determined that she was a poor surgical candidate. Today she presents to your clinic with the same persistent complaints.

What is the best possible treatment option for this patient?

Ursodeoxycholic acid

Urosodeoxycholic acid and chenodeoxycholic acid together

Insist that the patient undergo cholecystectomy

Augmentin

Key Concept/Objective: To understand the role of dissolution therapy in patients who are poor surgical candidates Oral bile acids such as ursodeoxycholic acid (8 to 12 mg/kg/day) and chenodeoxycholic acid (13 to 15 mg/kg/day) can decrease biliary cholesterol levels with complete gallstone dissolution; when administered for months to years, ursodeoxycholic acid and chenodeoxycholic acid can result in complete gallstone dissolution in 30% and 14% of patients, respectively. In one study, combination therapy with these two agents was not found to be superior to monotherapy with ursodeoxycholic acid. Chenodeoxycholic acid has largely been replaced by the safer ursodeoxycholic acid. However, these drugs are effective only in patients who have small cholesterol stones and a functioning gallbladder. A high rate of gallstone recurrence is noted after cessation of therapy. The infusion of methyl tert-butyl ether through a transhepatic catheter directly into the gallbladder can rapidly dissolve cholesterol stones. The rapid infusion and removal of this ether, which remains liquid at body temperature, results in the dissolution of most cholesterol gallstones within 4 to 31 hours. Dissolution therapy has limited value except in patients who are poor candidates for surgery.

Explanation

Key Concept/Objective: To understand the role of dissolution therapy in patients who are poor surgical candidates Oral bile acids such as ursodeoxycholic acid (8 to 12 mg/kg/day) and chenodeoxycholic acid (13 to 15 mg/kg/day) can decrease biliary cholesterol levels with complete gallstone dissolution; when administered for months to years, ursodeoxycholic acid and chenodeoxycholic acid can result in complete gallstone dissolution in 30% and 14% of patients, respectively. In one study, combination therapy with these two agents was not found to be superior to monotherapy with ursodeoxycholic acid. Chenodeoxycholic acid has largely been replaced by the safer ursodeoxycholic acid. However, these drugs are effective only in patients who have small cholesterol stones and a functioning gallbladder. A high rate of gallstone recurrence is noted after cessation of therapy. The infusion of methyl tert-butyl ether through a transhepatic catheter directly into the gallbladder can rapidly dissolve cholesterol stones. The rapid infusion and removal of this ether, which remains liquid at body temperature, results in the dissolution of most cholesterol gallstones within 4 to 31 hours. Dissolution therapy has limited value except in patients who are poor candidates for surgery.

9.

A 45-year-old woman presents to the emergency department complaining of right upper quadrant pain, fever, and nausea of 8 hours' duration. On examination, the patient is found to have right upper quadrant tenderness. Laboratory evaluation reveals leukocytosis and a bilirubin level of 2.5 mg/dl.

Which of the following tests is the most accurate method of confirming the clinical diagnosis of acute cholecystitis?

Abdominal ultrasound

Cholescintigraphy

Abdominal CT

Abdominal x-ray

Key Concept/Objective: To understand the different imaging modalities for diagnosing cholecystitis
Transabdominal ultrasonography is the diagnostic procedure of choice for a patient with suspected gallstones and acute cholecystitis. A meta-analysis revealed that ultrasonography has a sensitivity of 88% to 90% and a specificity of 97% to 98% for the diagnosis of gallstones greater than 2 mm in size. Gallbladder ultrasonography should ideally be preceded by an 8-hour fast, because gallstones are best visualized in a distended, bile-filled gallbladder. Cholescintigraphy is the best method of confirming the clinical diagnosis of acute cholecystitis. This procedure, which takes only 60 to 90 minutes, involves the intravenous injection of technetium-99m-labeled hepatoiminodiacetic acid (HIDA, or lidofenin), which is selectively excreted into the biliary tree and enters the gallbladder. In the presence of acute cholecystitis, radiolabeled material enters the common bile duct and duodenum but not the gallbladder. A meta-analysis suggested that radionuclide scanning is the most accurate method of diagnosing acute cholecystitis. Occasionally, the scan gives false positive results in patients who have alcoholic liver disease, in those who are fasting, or in those receiving total parenteral nutrition; however, false negative results are rare. Radionuclide scanning may not be useful for patients with deep jaundice, because the labeled agent fails to enter the biliary tree.

Explanation

Key Concept/Objective: To understand the different imaging modalities for diagnosing cholecystitis
Transabdominal ultrasonography is the diagnostic procedure of choice for a patient with suspected gallstones and acute cholecystitis. A meta-analysis revealed that ultrasonography has a sensitivity of 88% to 90% and a specificity of 97% to 98% for the diagnosis of gallstones greater than 2 mm in size. Gallbladder ultrasonography should ideally be preceded by an 8-hour fast, because gallstones are best visualized in a distended, bile-filled gallbladder. Cholescintigraphy is the best method of confirming the clinical diagnosis of acute cholecystitis. This procedure, which takes only 60 to 90 minutes, involves the intravenous injection of technetium-99m-labeled hepatoiminodiacetic acid (HIDA, or lidofenin), which is selectively excreted into the biliary tree and enters the gallbladder. In the presence of acute cholecystitis, radiolabeled material enters the common bile duct and duodenum but not the gallbladder. A meta-analysis suggested that radionuclide scanning is the most accurate method of diagnosing acute cholecystitis. Occasionally, the scan gives false positive results in patients who have alcoholic liver disease, in those who are fasting, or in those receiving total parenteral nutrition; however, false negative results are rare. Radionuclide scanning may not be useful for patients with deep jaundice, because the labeled agent fails to enter the biliary tree.

10.

A 57-year-old man presents to the emergency departmentwith a 3-day history of nausea, vomiting, right upperquadrant pain, and fevers. In the emergency department, histemperature is 38.7° C (101.7° F), pulse is 120 beats/min, andblood pressure is 90/60 mm Hg. He is jaundiced and drowsybut arousable and oriented to person only. There is markedtenderness in the right upper quadrant and an inspiratorypause with palpation but no organomegaly or reboundtenderness. Bowel sounds are diminished, and the stoolexamination did not show occult blood. His leukocyte countis 23,000, with 80% neutrophils and 12% band forms.Hemoglobin is 19 g/dL, total bilirubin is 3.8 mg/dL, directbilirubin is 3.0 mg/dL, alkaline phosphatase is 295 U/L,aspartate aminotransferase (AST) is 210 U/L, alanineaminotransferase (ALT) is 232 U/L, and serum creatinine is2.1 mg/dL. A transabdominal sonogram shows multiplestones in the gallbladder; diffuse gallbladder wall thickening,and 11 mm of common bile duct dilation. After initiationof intravenous fl uids and empiric antibiotics, the patientis transferred to the intensive care unit for furthermanagement.

Which one of the following treatment options is most benefi cial in this patient?

Emergent laparoscopic cholecystectomy

Placement of a cholecystostomy tube under ultrasound guidance

Placement of a nasogastric tube for administration of bile binding resins

Observation for 1 week followed by outpatient surgical intervention

Key Concept/Objective: To recall that in unstable patients with cholangitis, placement of a cholecystotomy tube improves mortality In patients with acute cholecystitis, laparoscopic cholecystectomy should be performed within 96 hours of the onset of symptoms because the increasing infl ammatory changes that occur over time have been implicated in bile duct injury; these changes may necessitate converting the procedure to an open cholecystectomy. Some patients (e.g., those with septic shock, peritonitis, severe pancreatitis, portal hypertension, or marked clotting disorders) are not candidates for laparoscopic cholecystectomy. These patients should generally undergo either open cholecystectomy, if their condition permits, or simple cholecystostomy. Cholecystostomy, either operative or percutaneous and performed under ultrasound guidance, involves extracting the stones and draining the biliary tree through a catheter left in the gallbladder. Percutaneous cholecystostomy is superior to gallbladder aspiration in severe acute cholecystitis. Cholangiography can be carried out later through this drainage catheter. For patients who respond to cholecystostomy and who improve enough to become candidates for elective surgery, interval November 2008 â?? 8 cholecystectomy is recommended because the risk of recurrent symptoms is signifi cant. Endoscopic interventions in experienced hands may have a role in treating acute cholecystitis. Endoscopic ultrasound-guided transmural cholecystostomy and ERCP with sphincterotomy has been used in small groups of elderly or high-risk patients with acute cholecystitis.

Explanation

Key Concept/Objective: To recall that in unstable patients with cholangitis, placement of a cholecystotomy tube improves mortality In patients with acute cholecystitis, laparoscopic cholecystectomy should be performed within 96 hours of the onset of symptoms because the increasing infl ammatory changes that occur over time have been implicated in bile duct injury; these changes may necessitate converting the procedure to an open cholecystectomy. Some patients (e.g., those with septic shock, peritonitis, severe pancreatitis, portal hypertension, or marked clotting disorders) are not candidates for laparoscopic cholecystectomy. These patients should generally undergo either open cholecystectomy, if their condition permits, or simple cholecystostomy. Cholecystostomy, either operative or percutaneous and performed under ultrasound guidance, involves extracting the stones and draining the biliary tree through a catheter left in the gallbladder. Percutaneous cholecystostomy is superior to gallbladder aspiration in severe acute cholecystitis. Cholangiography can be carried out later through this drainage catheter. For patients who respond to cholecystostomy and who improve enough to become candidates for elective surgery, interval November 2008 â?? 8 cholecystectomy is recommended because the risk of recurrent symptoms is signifi cant. Endoscopic interventions in experienced hands may have a role in treating acute cholecystitis. Endoscopic ultrasound-guided transmural cholecystostomy and ERCP with sphincterotomy has been used in small groups of elderly or high-risk patients with acute cholecystitis.