A 72-year-old male is in the intensive care unit eight days after endovascular repair for … — USMLE Step 2 CK

A $72$ -year-old male is in the intensive care unit eight days after endovascular repair for a ruptured descending thoracic aortic aneurysm. His recovery was complicated by severe hypovolemic shock requiring high-dose vasopressors for $72$ hours. Over the past $12$ hours, he has developed a fever and lethargy. Temperature is $39.2^\circ C$ ( $102.6^\circ F$ ), blood pressure is $105/65$ mm Hg, and heart rate is $118$ /min. Abdominal examination reveals moderate distension, and palpation of the right upper quadrant elicits localized guarding. Laboratory studies show a leukocyte count of $19,500/mm^3$ with $14\%$ bands. Liver function tests show a mildly elevated alkaline phosphatase with normal transaminases. Bedside ultrasonography demonstrates a markedly distended gallbladder with a wall thickness of $6$ mm, distinct pericholecystic fluid, and no sonographic evidence of gallstones. The common bile duct measures $4$ mm in diameter. Which of the following is the most appropriate next step in management?

Image-guided percutaneous cholecystostomyCevap
B
Urgent laparoscopic cholecystectomy
C
Radionuclide biliary scintigraphy
D
Endoscopic retrograde cholangiopancreatography
E
Intravenous antimicrobial therapy and clinical observation

Cevap

The most appropriate next step in management is image-guided percutaneous cholecystostomy.

The patient has acute acalculous cholecystitis (AAC), a severe inflammation of the gallbladder that occurs in critically ill patients, typically following major surgery, trauma, or prolonged shock. The pathogenesis involves gallbladder stasis and ischemia, often exacerbated by vasopressor use and lack of enteral stimulation, leading to secondary bacterial infection. The ultrasound findings of gallbladder wall thickening, pericholecystic fluid, and absence of gallstones in a critically ill patient are highly specific for this diagnosis. Because patients with AAC are usually critically ill with high operative risk, the treatment of choice is immediate gallbladder drainage via image-guided percutaneous cholecystostomy alongside systemic antibiotics. Definitive cholecystectomy can be considered later if the patient recovers and becomes a suitable surgical candidate.

Adım Adım Çözüm

Synthesize the clinical presentation and history

Critically ill patient on postoperative day

8

after aortic repair and prolonged shock, presenting with new fever, right upper quadrant pain, and leukocytosis.

To identify the most likely category of postoperative complication.

Interpret the bedside imaging and laboratory findings

Ultrasound reveals a thickened gallbladder wall and pericholecystic fluid without gallstones, alongside a normal common bile duct.

To confirm the specific diagnosis of acute acalculous cholecystitis.

Determine the optimal management based on patient stability

Select image-guided percutaneous cholecystostomy.

The patient is critically ill and a poor operative candidate, making minimally invasive percutaneous drainage the safest and most effective method for source control.

Anahtar Kavram

Management of acute acalculous cholecystitis in critically ill postoperative patients

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Konular

Bu konudan daha fazla soru