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Difficulty: MediumPreoperative and Postoperative Care

A 68-year-old man is evaluated in the intensive care unit on postoperative day 14 following an emergency open repair of a ruptured abdominal aortic aneurysm. His postoperative course has been complicated by prolonged mechanical ventilation and the need for a continuous norepinephrine infusion to maintain adequate perfusion. Over the past 24 hours, his temperature has increased to 39.239.2 °C (102.6102.6 °F). His abdomen is distended, but deep sedation prevents a reliable assessment of tenderness. Laboratory studies show a leukocyte count of 19,500/mm319,500/mm^3, a total bilirubin of 3.23.2 mg/dL, and an alkaline phosphatase of 350350 U/L. A bedside right upper quadrant ultrasound demonstrates a markedly distended gallbladder with a wall thickness of 55 mm and the presence of pericholecystic fluid. No echogenic structures with acoustic shadowing are seen within the gallbladder lumen, and the common bile duct measures 44 mm in diameter. Which of the following is the most appropriate next step in the management of this patient?

  1. Percutaneous cholecystostomy tube placementAnswer
  2. B
    Endoscopic retrograde cholangiopancreatography
  3. C
    Computed tomography of the abdomen and pelvis
  4. D
    Intravenous broad-spectrum antibiotics and clinical observation
  5. E
    Laparoscopic cholecystectomy

Answer

The correct answer is percutaneous cholecystostomy tube placement.
This patient's presentation of fever, marked leukocytosis, and cholestatic liver enzymes in the setting of critical illness strongly suggests acute acalculous cholecystitis. The bedside ultrasound findings of a thickened gallbladder wall (55 mm) and pericholecystic fluid without gallstones confirm this diagnosis. In critically ill, hemodynamically unstable patients who are poor candidates for surgery, the standard treatment is immediate gallbladder decompression via percutaneous cholecystostomy tube placement along with the administration of intravenous antibiotics.

Step-by-Step Solution

1
Evaluate the clinical presentation and vital signs of the postoperative patient.
The patient is critically ill, mechanically ventilated, and dependent on vasopressors, presenting with a new-onset high fever and leukocytosis on postoperative day 14.
To identify that the patient is hemodynamically unstable and has developed a severe, late postoperative infectious complication.
2
Interpret the laboratory and imaging findings.
Elevated bilirubin and alkaline phosphatase suggest a biliary process. Bedside ultrasound confirms a thick-walled gallbladder and pericholecystic fluid without gallstones, with a normal common bile duct.
To diagnose acute acalculous cholecystitis (AAC), a classic complication in intensive care patients suffering from stasis and ischemia.
3
Determine the safest management strategy based on the patient's hemodynamic status.
Because the patient is too unstable to tolerate general anesthesia and surgery, percutaneous drainage is chosen as a minimally invasive alternative.
To establish immediate source control of the infection while avoiding the prohibitive mortality risk of surgery in a critically ill patient.

Key Concept

Acute acalculous cholecystitis typically affects critically ill patients and is optimally managed initially with percutaneous cholecystostomy and intravenous antibiotics due to the high surgical risk.
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Topics

Preoperative and Postoperative Care

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