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Zorluk: OrtaPreoperative and Postoperative Care

A 72-year-old man is evaluated in the intensive care unit on postoperative day 14 following an emergent open repair of a ruptured abdominal aortic aneurysm. His postoperative course has been complicated by prolonged mechanical ventilation and acute kidney injury requiring temporary hemodialysis. He is currently receiving enteral nutrition via a nasogastric tube. Over the last 12 hours, his temperature has increased to 39.2°C (102.6°F) and his blood pressure has dropped to 88/56 mm Hg. His pulse is 122/min and respirations are 22/min on the ventilator. Physical examination is notable for right upper quadrant rigidity and guarding upon palpation. Laboratory studies show a leukocyte count of 22,500/mm³. A bedside right upper quadrant ultrasound reveals a distended gallbladder with a wall thickness of 6 mm, pericholecystic fluid, and no evidence of gallstones. Which of the following is the most appropriate next step in the management of this patient?

  1. Placement of a percutaneous cholecystostomy tubeCevap
  2. B
    Emergent transport to the operating room for laparoscopic cholecystectomy
  3. C
    Transport to the radiology suite for a contrast-enhanced computed tomography scan of the abdomen
  4. D
    Escalation of antimicrobial therapy to intravenous meropenem and vancomycin as sole therapy
  5. E
    Performance of a bilateral lower extremity venous duplex ultrasound

Cevap

Placement of a percutaneous cholecystostomy tube
This patient has developed acute acalculous cholecystitis, a severe inflammation of the gallbladder occurring without gallstones. It classically affects critically ill patients (e.g., severe trauma, prolonged ICU stay, mechanical ventilation, parenteral or enteral nutrition). The pathogenesis involves gallbladder stasis and ischemia, leading to inflammation and secondary bacterial infection. The patient's clinical presentation of fever, leukocytosis, right upper quadrant guarding, and shock strongly supports this diagnosis. The bedside ultrasound findings of a thickened gallbladder wall (>3 mm) and pericholecystic fluid confirm it. Because this patient is hemodynamically unstable and critically ill, he is a prohibitive candidate for surgery. Therefore, the most appropriate management is the placement of a percutaneous cholecystostomy tube. This provides immediate decompression and drainage of the infected gallbladder, stabilizing the patient until they may potentially undergo a definitive cholecystectomy after recovery.

Adım Adım Çözüm

1
Identify the primary diagnosis from the clinical and imaging findings.
The combination of fever, leukocytosis, right upper quadrant pain, and an ultrasound showing gallbladder wall thickening and pericholecystic fluid without stones in an ICU patient indicates acute acalculous cholecystitis.
Recognizing the pathology is required to determine the proper management pathway.
2
Assess the patient's hemodynamic stability and surgical risk.
The patient has a blood pressure of 88/56 mm Hg, is mechanically ventilated, and has multiorgan failure, making him highly unstable and a prohibitive surgical risk.
Surgical risk stratification determines whether source control should be achieved surgically (cholecystectomy) or via minimally invasive drainage (cholecystostomy).
3
Select the safest, most effective intervention.
Percutaneous cholecystostomy tube placement is selected.
It provides immediate decompression and source control of the infected gallbladder under local anesthesia, avoiding the high mortality of general anesthesia in this shock state.

Anahtar Kavram

Acute acalculous cholecystitis typically affects critically ill, hospitalized patients. The standard treatment for patients who are hemodynamically unstable or poor surgical candidates is antibiotics combined with percutaneous cholecystostomy.
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Preoperative and Postoperative Care

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