Pop quiz: gallbladder
Answer the question below and see how your answer stacks up!
A 45-year-old man has a 50% total body surface area third-degree burn. Fever, marked leukocytosis, and right upper quadrant pain develop on hospital day 7. His blood pressure is 130/80 mm-Hg, and his heart rate is 110 beats per minute. Ultrasonography shows a distended gallbladder with gallbladder wall thickening and sludge. However, it is negative for gallstones. Antibiotics are initiated. The next step in management would consist of:
A. Laparoscopic cholecystectomy
B. Computed tomography
C. Hepatobiliary iminodiacetic acid (HIDA) scan
D. Percutaneous cholecystostomy
E. Upper endoscopy
Answer will be posted in the notes in the coming days
Answer is A: The presentation is consistent with acalculous cholecystitis. The initial study of choice is ultrasonography, which can be performed at the bedside. Findings to confirm the diagnosis would include thickening of the gallbladder wall, sludge (as in this patient), and pericholecystic fluid. If the ultrasound findings are negative and the patient is not critically ill, the next study would be a HIDA scan with sincalide or morphine. A positive study finding would demonstrate nonfilling of the gallbladder with visualization of the tracer in the liver and small bowel. Morphine decreases the rate of false-positive HIDA scan results because it leads to sphincter of Oddi contraction and thus increases the likelihood of filling of the gallbladder in the absence of cholecystitis. A HIDA scan is not recommended in critically ill patients in whom a delay in therapy can be potentially fatal (C). Acalculous cholecystitis requires urgent intervention, preferably cholecystectomy. The procedure can be attempted laparoscopically; however, there is a higher chance of finding gangrenous cholecystitis and needing to convert to open. If the patient is too ill for surgery, percutaneous ultrasonography or CT-guided cholecystostomy is the treatment option of choice (B, D). Upper endoscopy is not indicated (E).