Twelve days ago, a 72-year-old man underwent an emergency exploratory laparotomy with bowe… — USMLE Step 2 CK

Twelve days ago, a 72-year-old man underwent an emergency exploratory laparotomy with bowel resection for acute mesenteric ischemia. He remains in the intensive care unit on mechanical ventilation and receives total parenteral nutrition. Over the past 24 hours, his body temperature has increased to $39.2^\circ\text{C}$ ( $102.6^\circ\text{F}$ ). His blood pressure is $92/62\text{ mmHg}$ and his pulse is $116/\text{min}$ . The abdominal incision is clean and intact. Physical examination reveals localized guarding in the right upper abdominal quadrant when palpated. Laboratory results demonstrate a leukocyte count of $19,500/\text{mm}^3$ , total bilirubin of $2.9\text{ mg/dL}$ , and alkaline phosphatase of $350\text{ U/L}$ . A bedside abdominal ultrasound shows a gallbladder wall thickness of $6\text{ mm}$ , pericholecystic fluid, and no visible gallstones or biliary ductal dilation. Which of the following is the most appropriate next step in management?

Placement of a percutaneous cholecystostomy tubeAnswer
B
Endoscopic retrograde cholangiopancreatography
C
Surgical cholecystectomy
D
Intravenous administration of ceftriaxone and metronidazole as monotherapy
E
Computed tomography imaging of the abdomen and pelvis

Answer

The most appropriate next step is the placement of a percutaneous cholecystostomy tube to decompress the infected gallbladder in this critically ill patient.

This patient has acute acalculous cholecystitis, an inflammatory condition of the gallbladder seen in critically ill patients (e.g., sepsis, major trauma, mechanical ventilation, prolonged total parenteral nutrition). The pathogenesis involves gallbladder stasis and ischemia, leading to inflammation and secondary bacterial infection. The diagnosis is confirmed by ultrasound demonstrating a thickened gallbladder wall, pericholecystic fluid, and absence of gallstones. While cholecystectomy is the definitive treatment, critically ill patients are often too unstable to tolerate surgery. Therefore, the standard of care is broad-spectrum intravenous antibiotics combined with the placement of a percutaneous cholecystostomy tube for immediate gallbladder decompression and source control.

Step-by-Step Solution

Analyze the patient's clinical presentation and risk factors.

The patient is critically ill, mechanically ventilated, and receiving total parenteral nutrition (TPN), which are major risk factors for acute acalculous cholecystitis due to gallbladder stasis and ischemia.

Identifying the risk profile narrows down the differential diagnosis for a new-onset fever in the intensive care unit.

Interpret the diagnostic findings.

Ultrasound reveals gallbladder wall thickening (

>4\text{ mm}

) and pericholecystic fluid without stones or biliary dilation, confirming acute acalculous cholecystitis.

Correlating physical signs (right upper quadrant guarding) with imaging establishes a definitive diagnosis.

Determine the optimal management strategy based on patient stability.

Because the patient is hemodynamically unstable (

92/62\text{ mmHg}

) and critically ill, surgical intervention is too high risk, making percutaneous drainage the treatment of choice.

Management must balance the need for source control against the patient's ability to tolerate physiological stress.

Key Concept

Acute acalculous cholecystitis typically occurs in critically ill patients (e.g., trauma, mechanical ventilation, TPN) and is initially managed with broad-spectrum antibiotics and percutaneous cholecystostomy tube placement due to high surgical risk.

Estimated Time:1m 15s

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