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Difficulty: EasySurgical and Procedural Interventions

A 7474-year-old female patient in the intensive care unit is evaluated for a new-onset fever and right upper quadrant abdominal pain. She was admitted 1010 days ago for severe bacterial pneumonia requiring mechanical ventilation. Her temperature is 39.2∘C39.2^\circ\text{C} (102.6∘F102.6^\circ\text{F}), blood pressure is 85/54 mm Hg85/54\text{ mm Hg}, and pulse is 126/min126/\text{min}. Physical examination shows right upper quadrant tenderness and guarding. Laboratory studies reveal a leukocyte count of 19,000/mm319,000/\text{mm}^3. A bedside right upper quadrant ultrasound demonstrates a thickened gallbladder wall, pericholecystic fluid, and an absence of gallstones. The patient is currently receiving broad-spectrum intravenous antibiotics and vasopressor support. Which of the following is the most appropriate next step in management?

  1. Placement of a percutaneous cholecystostomy tubeAnswer
  2. B
    Immediate open cholecystectomy
  3. C
    Transfer to the radiology suite for a computed tomography scan
  4. D
    Hepatobiliary iminodiacetic acid (HIDA) scan
  5. E
    Endoscopic retrograde cholangiopancreatography

Answer

Placement of a percutaneous cholecystostomy tube
The patient has acute acalculous cholecystitis, a severe inflammation of the gallbladder seen typically in critically ill, hospitalized patients (e.g., those with sepsis, burns, or on prolonged mechanical ventilation). Although the definitive treatment for gallbladder inflammation is a cholecystectomy, this patient is hemodynamically unstable, dependent on vasopressors, and requiring mechanical ventilation. These factors make her an extremely poor surgical candidate with prohibitively high operative mortality. Therefore, the most appropriate procedural intervention is the placement of a percutaneous cholecystostomy tube. This procedure can often be performed at the bedside, providing immediate, life-saving decompression of the infected gallbladder and achieving source control while minimizing physiologic stress.

Step-by-Step Solution

1
Identify the patient's diagnosis based on the clinical presentation and imaging.
The combination of fever, right upper quadrant pain, leukocytosis, and an ultrasound showing gallbladder inflammation without stones in a critically ill patient indicates acute acalculous cholecystitis.
Establishing the correct diagnosis is the prerequisite for determining the appropriate intervention.
2
Assess the patient's surgical risk and hemodynamic stability.
The patient is in shock, requiring vasopressors and mechanical ventilation, making her an extremely poor candidate for general anesthesia and surgery.
The choice between definitive surgery and temporizing procedural drainage depends directly on the patient's stability.
3
Select the safest, most effective procedural intervention for source control.
Percutaneous drainage is chosen over cholecystectomy.
It provides immediate gallbladder decompression and source control with minimal physiological stress compared to open or laparoscopic surgery.

Key Concept

Procedural management of acute acalculous cholecystitis in critically ill, unstable patients relies on percutaneous cholecystostomy rather than surgical cholecystectomy.
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Topics

Surgical and Procedural Interventions

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