A 78-year-old man is evaluated in the intensive care unit for a new-onset fever. He was ad… — USMLE Step 3

A 78-year-old man is evaluated in the intensive care unit for a new-onset fever. He was admitted 4 days ago for severe community-acquired pneumonia and currently requires mechanical ventilation and continuous norepinephrine infusion to maintain adequate perfusion. His past medical history is significant for severe chronic obstructive pulmonary disease and ischemic cardiomyopathy with an ejection fraction of $25\%$ . Temperature is $39.2^\circ\text{C}$ ( $102.6^\circ\text{F}$ ), blood pressure is $90/60\text{ mmHg}$ (on vasopressors), pulse is $115/\text{min}$ , and respirations are fully supported by the ventilator. Physical examination reveals a sedated patient who grimaces and guards when deep palpation is applied to the right upper quadrant. Laboratory studies show a leukocyte count of $22,000/\mu\text{L}$ , total bilirubin of $1.8\text{ mg/dL}$ , and alkaline phosphatase of $210\text{ U/L}$ . Aminotransferase levels are within normal limits. A right upper quadrant ultrasound demonstrates a markedly distended gallbladder with a wall thickness of $6\text{ mm}$ , pericholecystic fluid, and biliary sludge, but no gallstones are visualized. Which of the following is the most appropriate next step in the management of this patient's abdominal condition?

Placement of a percutaneous cholecystostomy tubeCevap
B
Laparoscopic cholecystectomy
C
Endoscopic retrograde cholangiopancreatography
D
Broad-spectrum antibiotics and supportive care alone
E
Hepatobiliary iminodiacetic acid (HIDA) scan

Cevap

Placement of a percutaneous cholecystostomy tube is the correct management step.

This patient has developed acute acalculous cholecystitis, a highly morbid condition typically seen in critically ill, hospitalized patients (e.g., those requiring mechanical ventilation, vasopressors, or total parenteral nutrition). The lack of enteral feeding leads to biliary stasis, ischemia, and subsequent inflammation. Prompt source control is necessary to prevent gallbladder necrosis, gangrene, and perforation. While cholecystectomy is the definitive treatment, this patient is hemodynamically unstable, dependent on a ventilator, and has severe underlying cardiac disease, making him an extremely poor surgical candidate. In such high-risk patients, percutaneous cholecystostomy tube placement is the preferred procedural intervention. It effectively decompresses the infected gallbladder and provides source control under local anesthesia, bridging the patient to definitive surgery once they recover or serving as a definitive treatment if they remain unfit for surgery.

Adım Adım Çözüm

Diagnose the acute condition based on clinical and ultrasound findings.

The patient has acute acalculous cholecystitis, characterized by fever, leukocytosis, right upper quadrant tenderness, and ultrasound findings of gallbladder wall thickening and pericholecystic fluid without gallstones in the setting of critical illness.

Establishing the correct diagnosis guides the urgency and type of intervention.

Evaluate the patient's surgical risk and hemodynamic stability.

The patient is on vasopressors, requires mechanical ventilation, and has a severe ischemic cardiomyopathy (EF

25\%

), making him a prohibitively high-risk candidate for surgical intervention under general anesthesia.

Surgical risk stratification determines whether definitive treatment (cholecystectomy) or a temporizing, minimally invasive measure is required.

Select the safest procedural intervention for source control.

Percutaneous cholecystostomy tube placement provides necessary gallbladder decompression and source control without the hemodynamic stress of surgery.

Critically ill patients with acalculous cholecystitis require drainage to prevent gallbladder necrosis and perforation.

Anahtar Kavram

In critically ill patients who develop acute acalculous cholecystitis and are poor surgical candidates, placement of a percutaneous cholecystostomy tube is the most appropriate procedural intervention for source control.

Soru

Cevap

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Anahtar Kavram

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