Uncover a medical case study: 53-year-old man with abdominal pain, jaundice, and fever. Learn about the next steps in management. Enhance your medical knowledge with this USMLE® Step 2-style practice question.
A 53-year-old man presents to the emergency department for evaluation of cramping abdominal pain, and yellow skin. The pain started last night and is associated with nausea and non-bloody vomiting. The patient has no significant past medical history. Temperature is 39 ºC (102.2 ºF), pulse is 108/min, blood pressure is 140/75 mmHg, respiratory rate is 18/min, and SpO2 is 100% on room air. On physical examination, the patient appears ill with jaundice and scleral icterus. There is moderate tenderness to palpation in the right upper quadrant. Laboratory evaluation shows leukocytosis and hyperbilirubinemia. Which of the following is the most appropriate next step in management?A. Emergent general surgery consult
B. Gastroenterology consult for endoscopic retrograde cholangiopancreatography
C. CT of the abdomen and pelvis with IV contrast
D. Administration of IV antibiotics with ceftriaxone
The correct answer to today’s USMLE® Step 2 CK Question is…
B. Gastroenterology consult for endoscopic retrograde cholangiopancreatography
Before we get to the Main Explanation, let’s see why the answer wasn’t A, C, D. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
A. Emergent general surgery consult
Incorrect: This patient likely has acute cholangitis suspected because of the findings of right upper quadrant abdominal pain, fever, and jaundice (Charcot Triad). Gastroenterology should be consulted for an ERCP.
C. CT of the abdomen and pelvis with IV contrast
Incorrect: Abdominal CT can detect biliary duct dilatation and biliary stenosis; however, it has low sensitivity for detecting biliary tract stones. This patient has features suggestive of acute cholangitis–warranting ERCP for diagnosis and treatment.
D. Administration of IV antibiotics with ceftriaxone
Incorrect: This patient with acute cholangitis should have empiric antibiotics initiated to cover enteric streptococci, coliforms, and anaerobes. Ceftriaxone should not be used alone in acute cholangitis, but should be prescribed in combination with metronidazole.
Main Explanation
Biliary colic is described as an intense, dull discomfort, typically constant in nature in the right upper quadrant, epigastrium, or substernal area with possible radiation to the back or right shoulder blade. Pain from biliary colic is often associated with fatty food intake, nausea, and vomiting. Biliary colic is typically caused by the gallbladder contracting and forcing a gallstone or sludge against the gallbladder outlet or cystic duct opening.
Complications of gallstones include cholecystitis which is right upper quadrant pain, fever, and leukocytosis from gallbladder inflammation secondary to gallstones. Another complication of gallstones is choledocholithiasis which is the presence of a gallstone in the common bile duct. This can be further complicated by acute cholangitis which presents with fever, abdominal pain, and jaundice caused by infection from biliary obstruction. This patient has evidence of right upper quadrant pain, jaundice, fever, leukocytosis, and hyperbilirubinemia suggesting acute cholangitis. The combination of fever, abdominal pain, and jaundice is known as Charcot’s triad, which is highly suggestive of acute cholangitis.
Patients with biliary colic should have lab work including a CBC to assess for leukocytosis and a CMP, and liver function tests. The initial imaging for biliary colic is typically abdominal ultrasound to look for gallstones. For patients with obesity or other anatomic considerations endoscopic ultrasound can be used.
Endoscopic retrograde cholangiopancreatography (ERCP), with or without an initial ultrasound, should be performed in patients with suspected acute cholangitis since it can be used to both diagnose and treat the underlying obstruction via biliary duct decompression and removal of stones. In addition, patients with acute cholangitis should be admitted to the hospital and administered IV hydration, antiemetics, analgesia, and empiric antibiotics.
Major Takeaway
Patients with suspected acute cholangitis should undergo ERCP for both diagnosis and treatment with biliary drainage. __________________________
____________________________
Try Osmosis today! Access your free trial and find out why millions of clinicians and caregivers love learning with us.
Leave a Reply