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Old 12-02-2012
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Arrow Internal Medicine-Gastrointestinal Q #3

A 35-year-old obese woman presents to the emergency department complaining of severe epigastric right upper quadrant pain that has been unrelenting for 24 hours. She has fevers, rigors, nausea, and vomiting. Results of physical examination are as follows: temperature, 102.2° F (39° C); blood pressure, 120/65 mm Hg; pulse, 100 beats/min; and respirations, 18 breaths/min. The patient looks ill and slightly jaundiced. She is shivering beneath a pile of blankets. Bowel sounds are hypoactive. There is marked right upper quadrant tenderness but no palpable liver or gallbladder. Laboratory results show a white blood cell count of 16,000 with a left shift. Bilirubin is 4.5, and alkaline phosphatase is 260. Her amylase level is normal. Which of the following represents the diagnosis and best treatment for this patient?


A. Acute cholecystitis; treat with ampicillin-sulbactam
B. Acute cholecystitis; treat with ceftriaxone
C. Cholangitis; treat with ampicillin-sulbactam
D. Cholangitis; treat with ceftriaxone
E. None of the above
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B. Acute cholecystitis; treat with ceftriaxone
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raised Alk Phosphate should be D.
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yup D .................
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Quote:
Originally Posted by heartbeat View Post
A 35-year-old obese woman presents to the emergency department complaining of severe epigastric right upper quadrant pain that has been unrelenting for 24 hours. She has fevers, rigors, nausea, and vomiting. Results of physical examination are as follows: temperature, 102.2° F (39° C); blood pressure, 120/65 mm Hg; pulse, 100 beats/min; and respirations, 18 breaths/min. The patient looks ill and slightly jaundiced. She is shivering beneath a pile of blankets. Bowel sounds are hypoactive. There is marked right upper quadrant tenderness but no palpable liver or gallbladder. Laboratory results show a white blood cell count of 16,000 with a left shift. Bilirubin is 4.5, and alkaline phosphatase is 260. Her amylase level is normal. Which of the following represents the diagnosis and best treatment for this patient?


A. Acute cholecystitis; treat with ampicillin-sulbactam
B. Acute cholecystitis; treat with ceftriaxone
C. Cholangitis; treat with ampicillin-sulbactam
D. Cholangitis; treat with ceftriaxone
E. None of the above
Obviously right answer is option D) as evident from presence of Charcot's triad: Fever with chills and rigor, Abdominal pain, Jaundice.
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Answer: C—Cholangitis; treat with ampicillin-sulbactam
This patient has the classic triad of jaundice, right upper quadrant pain, and fever with rigors (Charcot triad), which suggests cholangitis. If she also had shock and mental status changes (Reynold pentad), her prognosis would be grave: mortality in such patients approaches 50%. In addition to antibiotics and supportive care, patients who are very ill should be considered for biliary tract decompression (percutaneous or surgical decompression, or decompression with ERCP). The organisms that most commonly cause cholangitis are Escherichia coli, Klebsiella, enterococci, and Bacteroides fragilis . Ceftriaxone is not recommended in this case because it does not cover enterococci and has been associated with the development of gallbladder sludge.
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