Surgery>>>>>The Gallbladder and Extrahepatic Biliary System
Question 8#

A 54-year-old otherwise healthy woman presents to the emergency department with abdominal pain, fever, chills, and confusion. Blood pressure is 95/50, heart rate 1 10, and temperature 39°C. Laboratory tests demonstrate a white blood cell count of 15,000, normal hematocrit and platelets, as well as a direct bilirubin of 7.2. Initial management should be:

A. Emergency biliary decompression endoscopically or transhepatically
B. Emergent cholecystectomy
C. Intravenous (IV) fluid resuscitation and antibiotics
D. Observation and pain control
E. Discharge home with oral antibiotics with planned cholecystectomy in the coming weeks

Correct Answer is C

Comment:

The initial treatment of patients with cholangitis includes intravenous (IV) antibiotics and fluid resuscitation. These patients may require intensive care unit monitoring and vasopressor support. Most patients will respond to these measures. However, the obstructed bile duct must be drained as soon as the patient has been stabilized. About 15% of patients will not respond to antibiotics and fluid resuscitation, and an emergency biliary decompression may be required. Biliary decompression may be accomplished endoscopically, via the percutaneous transhepatic route, or surgically. The selection of procedure should be based on the level and the nature of the biliary obstruction. Patients with choledocholithiasis or periampullary malignancies are best approached endoscopically, with sphincterotomy and stone removal, or by placement of an endoscopic biliary stent. In patients in whom the obstruction is more proximal or perihilar, or when a stricture in a biliaryenteric anastomosis is the cause or the endoscopic route has failed, percutaneous transhepatic drainage is used. When neither ERCP nor percutaneous transhepatic cholangiography (PTC) is available, an emergent operation for decompression of the common bile duct with a T tube may be necessary and lifesaving. Definitive operative therapy should be deferred until the cholangitis has been treated and the proper diagnosis established. Patients with indwelling stents and cholangitis usually require repeated imaging and exchange of the stent over a guidewire.