Question of the Week # 172

172)  A 44 year old obese woman presents with complaints of abdominal pain in the right upper quadrant that started 4 hours ago and is persistent. She has mild nausea. On physical examination, there is tenderness in right upper quadrant which increases with deep breath. Her liver function tests are normal; WBC count is 24,000/µl with neutrophilic predominance. Amylase and Lipase are with in normal limits. An ultrasound of the gall bladder reveals gall stones but there is no pericholecystic fluid or any other sonographic evidence of acute cholecystitis. Sonographic murphy’s sign is absent. The most appropriate next step in managing this patient:

A)     Percutaneous Cholecystostomy

B)      Laparoscopic Cholecystectomy

C)      HIDA scan

D)     Endoscopic Retrograde Cholangiopancreatography (ERCP)

E)     Magnetic Resonance CholangiOpancreatography ( MRCP)

 

17 Responses

  1. bbbbbb

  2. An MRCP is usually done but if it is neg—it doesnt rule out cholelithiasis. An ERCP is more specific Surgery is too aggressive right now. Lets test for obstruction–ercp

  3. hida scan

  4. HIDA, if it doesnt show, means there r more gallstones i guess…..technically we would admit and do NPO, morphine, IVF. then later do a chole.

  5. and theres no criteria for ERCP in this q.

  6. oops im sorry. U/S shows gallstones, so do ERCP +/- stent and then lap chole

  7. B) Laparoscopic Cholecystectomy

  8. HIDA scan 🙂

    No one should do an elective Cholecystectomy without confirmation that the gallbladder is indeed inflamed . Would you want me to remove your gallbladder or cut you up just because you have RUQ flank pain ?

    indeed patient has risk factor : obese , early 40s ,

    I would prefer HIDA because since patient is not severely ill . She can wait a while for HIDA to show up . Non invasive .

    ECRCP is more hassle . And it might end up with pancreatitis as complication . Cystic duct junction is poorly visible with ERCP compared with HIDA .

    would like to hear from Dr.Redz opinion and answers

    Cheers

  9. I would order ERCP, can be diagnostic and therapeutic as well. It can actually dislodge if there is a stone!! I think!

  10. This is symptomatic biliary colic. Ultrasound shows gall stones in the gall bladder. Each time the gall bladder contracts, a gall stone obstructs the cystic duct, it causes symptoms. There is no current biliary tract obstruction, evident by normal liver function. Pancreatic function is also normal. There is no need for diagnostic studies or ‘going after’ hidden stones because her liver and pancreatic tests are normal beyond paranoia. The culprit stones are visible in the gall bladder. We know where the stones are and we know that currently there is no obstruction. Since liver and pancreatic enzyme function is normal.
    Sonographic Murphy’s sign is absent suggesting pain is mild, this is the best time to do laparoscopic cholecystectomy. (before patient takes another meal and suffers probably a more severe colic)

    Is it worrisome to consider surgery with his remarkable level of neutrophilia?
    Neutrophilia + abnormal liver or pancreatic enzymes = alarming!
    Neutrophilia alone, with no organ dysfunction, even 50,000 plus only suggest a stressful acute event.

    It will take 1-5 days for levels to return to normal. It is not wise to wait that long given the risk that a biliary colic can occur again anytime most likely, within the next 24 hrs. It’s like a time bomb waiting for the next biliary contraction. (Sexual arousal, lacrimation, salivation, urination, defecation, sleep, i.e, the next parasympathetic stimulus could be another biliary colic)

    I think the most appropriate next step is laparoscopic cholecystectomy. Answer is (b). If you are still not convinced, think of this as 80% symptomatic coronary or carotid stenosis. What would you do next?
    We want to prevent a foreseen event. So we operate. (This is the recommended guideline for symptomatic biliary colic.)

    • What’s important is to answer the correct answer in the exam — in UW question = similar question but with Ultrasound of the abdomen shows several “small stones” in the gallbladder without gallbladder edema or US Murphy sign, the common bile duct is not enlarged What is the best next step in management?HIDA – the clue is “that Archer never mention the size of the calculus if they were small or large because this is what makes the difference between HIDA (if positive =surgery negative medical treatment) and cholecystectomy –because Medical management is more effective in patients with good gallbladder function who have small stones ( 1 cm cholecystectomy is the right answer –because you never mentions the size of the calculi the best management is HIDA —the correct question is!! Is the bladder able to spit out the rocks or not 😦 –if not surgery treatment — if able give Oral bile salt therapy (ursodeoxycholic acid) and save his gallbladder and make your Pt keep it

  11. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124163/
    http://www.ncbi.nlm.nih.gov/pubmed/11768676
    It is highly possibility of acute cholecystitis. USG result did not show inflammation and it is not conclusive. HIDA scan is more sensitive for acute cholecystitis than USG. ultrasound is good for the stones but HIDA scan is good for cholecystitis.

  12. This is a very similar question in UW for CK. Answer is HIDA.

    When the suspicion for cholecystitis is high, but you dont have the US criteria for it (Pericholecystic fluid), Next best step is to get a HIDA scan. If you have the US criteria, then you dont need to do anything as cholecystitis is diagnosed.

    Also, consider the fact that many people have asymptomatic gallstones. You dont do surgery in all of them. When they get symptomatic, but US criteria is not clear, you have to confirm your suspicion that they are the ones causing the symptoms. So you also do a HIDA scan in that situation.

    • so its C)HIDA

  13. Some of my esteemed colleagues who commented on this question prefer imaging rather than cholecystectomy, especially doing a HIDA scan. How do we decide what is the most appropriate next step in the management of our patient? Is it imaging or surgery? The most appropriate next step in this/any scenario is to do something that will influence the outcome. We need to do something that will help us to make a decision or change a plan, drug or intervention.
    It may be hard for some of us to believe but doing HIDA will not influence our outcome in this question. Contrary to better expectations, it will not change the management. It will make no difference whether we do a HIDA scan or not, this patient is still going for the same outcome of cholecystectomy. HIDA makes no difference and it is not the most appropriate next step.

    Some may argue that we need to prove obstruction or cholecystitis first before surgery but this is not necessary if the management is the same regardless of the outcome. Our emphasis is not on proving that this is acute cholecystitis, it’s rather on detecting something that will help in the management. Suppose HIDA is positive what do we do? Surgery. Suppose we do a HIDA scan, and it is negative, what is it that we do differently? We still do laparoscopic cholecystectomy. So how did HIDA help us here? In this scenario, HIDA is unnecessary. HIDA may be useful to detect site of biliary leakage after accidental iatrogenic perforation of the biliary tree so that surgeons can locate precisely the point of leakage and fix it. This may happen after laparoscopic cholecystectomy or ERCP.

    The most appropriate next step in the management of painful symptomatic biliary colic that has persisted for 4 hours and ultrasound shows evidence of gall stones is cholecystectomy. There is no wisdom in delay here because gall stones are confirmed and our patient has classical symptoms of symptomatic biliary colic. It’s not mandatory to prove this is cholecystitis, the treatment is same for symptomatic biliary colics and we do not wait until cholecystitis sets in before we embark on surgery.
    HIDA will be useful is this patient to investigate biliary leakage after laparoscopic cholecystectomy. Sometime also useful when there is no obvious explanation for biliary colics or cholecystitis but here, gallstones are clearly visible in the gall bladder. Why will we start looking for cholecystitis? Why will we delay treatment? The symptom will not resolve unless the gall stones are removed. When stones are seen in the gall bladder, surgeons will do cholecystectomy for symptomatic stones. If there were no symptoms, of course we would leave the stones alone. This patient has symptoms.

    No, conservative management will not relief symptoms as long as there are gall stones in the gall bladder.

    ERCP may have been diagnostic and therapeutic if pancreatic or liver enzymes were elevated indicating CBDO
    MRCP is non invasive diagnostic imaging to locate the precise site or location of biliary tract obstruction.

    The most appropriate next step is laparoscopic cholecystectomy. No imaging study done right now will influence our management. Imaging studies are unnecessary right now.

    • I guess we need to do HIDA…There is a similar question in uworld where the pt had no sonographic evidence of acute cholecystitis…we got to do HIDA to confirm if the al bladder is actually inflamed….sorry but you r wrong in this case

  14. ee

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