An 82-year-old man is evaluated in the intensive care unit for persistent fever and clinic… — USMLE Step 3

An $82$ -year-old man is evaluated in the intensive care unit for persistent fever and clinical deterioration. He was admitted $8$ days ago for severe community-acquired pneumonia and respiratory failure requiring intubation and mechanical ventilation. His hospital course has been complicated by septic shock, for which he is currently receiving continuous infusions of norepinephrine and vasopressin. Today, his temperature is $39.2^\circ\text{C}$ ( $102.6^\circ\text{F}$ ), blood pressure is $86/52\text{ mmHg}$ , pulse is $122/\text{min}$ , and respiratory rate is $18/\text{min}$ (ventilator set). Physical examination reveals a distended abdomen with guarding in the right upper quadrant upon deep palpation. Laboratory studies show a leukocyte count of $24,000/\text{mm}^3$ (up from $14,000/\text{mm}^3$ yesterday). Liver function tests reveal a total bilirubin of $1.4\text{ mg/dL}$ , alkaline phosphatase of $130\text{ U/L}$ , aspartate aminotransferase of $45\text{ U/L}$ , and alanine aminotransferase of $40\text{ U/L}$ . A bedside right upper quadrant ultrasound demonstrates a markedly distended gallbladder with a thickened wall, pericholecystic fluid, and no stones or sludge. The common bile duct measures $4\text{ mm}$ in diameter. Intravenous meropenem is initiated. Which of the following is the most appropriate next step in the management of this patient?

A
Endoscopic retrograde cholangiopancreatography
B
Laparoscopic cholecystectomy
Percutaneous cholecystostomyAnswer
D
Continued medical management and serial abdominal ultrasound examinations
E
Hepatobiliary iminodiacetic acid scan

Answer

Percutaneous cholecystostomy is the most appropriate intervention for acute acalculous cholecystitis in a hemodynamically unstable patient.

The correct answer is percutaneous cholecystostomy. This patient presents with acute acalculous cholecystitis (AAC), a severe gallbladder inflammation occurring almost exclusively in critically ill patients (e.g., those with sepsis, major trauma, or prolonged mechanical ventilation). It is characterized by gallbladder distension, wall thickening, and pericholecystic fluid in the absence of gallstones. Immediate source control is imperative due to the high risk of gangrene and perforation. However, because this patient is hemodynamically unstable and receiving multiple vasopressors for septic shock, he is a prohibitive risk for general anesthesia and definitive surgery (cholecystectomy). Percutaneous cholecystostomy provides immediate, minimally invasive decompression and source control of the infected gallbladder, serving as a life-saving temporizing measure.

Step-by-Step Solution

Interpret the clinical and sonographic findings.

The combination of fever, right upper quadrant guarding, leukocytosis, and an ultrasound showing a thick-walled, distended gallbladder with pericholecystic fluid but no stones establishes the diagnosis of acute acalculous cholecystitis.

Accurate diagnosis is required before selecting a procedural intervention.

Assess the patient's physiologic reserve and suitability for surgery.

The patient is in persistent septic shock requiring dual vasopressor therapy (norepinephrine and vasopressin), making him a prohibitive risk for general anesthesia and surgical extirpation.

Surgical risk stratification determines whether definitive treatment or temporizing source control is indicated.

Determine the optimal intervention that balances source control with procedural risk.

Image-guided percutaneous cholecystostomy tube placement is selected to drain the infected gallbladder without subjecting the patient to the physiologic stress of surgery.

Minimally invasive drainage stabilizes critically ill patients until they recover sufficiently to undergo definitive cholecystectomy.

Key Concept

Management of acute acalculous cholecystitis in critically ill, hemodynamically unstable patients requires image-guided percutaneous cholecystostomy rather than definitive surgery.

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic