Question

A 54-year-old woman presents to the emergency department with nausea, vomiting, right-upper quadrant abdominal pain, fever, and jaundice starting 4 hours ago. During the last 6 months, she suffered several bouts of upper-abdominal pain accompanied by nausea, vomiting, and occasional jaundice, for which medical attention was sought. Her past medical history includes hyperlipidemia, for which she first took simvastatin; she switched to cholestyramine because of side effects.

Vital signs on admission are as follows: BP 110 / 80 mm Hg, HR 90 bpm, RR 20 rpm, temperature 38.1°C (100.6 F). She is alert and oriented, and mildly jaundiced. Her right-upper abdomen is diffusely tender to palpation.

An upper abdominal ultrasound is performed and reveals a thickening and calcifications of the gallbladder wall, but there are no signs of air within the peritoneal cavity or the bile ducts.

What is the most appropriate next step in management?

1 Intravenous hydration and antibiotics
2 Endoscopic papillotomy
3 Give analgesics and refer for elective cholecystectomy
4 Magnetic resonance cholangiography to look for choledocholithiasis
5 Emergency cholecystectomy

Answer 1

The most appropriate next step in management for the presenting symptoms and findings is intravenous hydration and antibiotics, along with analgesics for pain management, and a referral for elective cholecystectomy.

Step-by-step explanation:

The presentation of a 54-year-old woman with nausea, vomiting, right-upper quadrant abdominal pain, fever, and jaundice suggests acute cholecystitis or possibly cholangitis given the chronic history and ultrasonography findings of gallbladder wall thickening and calcifications. Although there is no evidence of air in the bile ducts or peritoneal cavity, the clinical presentation aligns with a gallbladder pathology. The most appropriate next step in management would be intravenous hydration and antibiotics (Option 1), which caters to stabilizing the patient and treating possible infection. Analgesics can be provided for symptom control.

Moreover, considering the recurrent episodes and current acute presentation, referral for elective cholecystectomy after stabilization would be prudent to prevent further complications. Emergency cholecystectomy is reserved for severe cases with complications such as perforation or gangrene. Magnetic resonance cholangiography might not be immediately necessary unless there is suspicion for choledocholithiasis after initial management.