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  #1  
Old 05-12-2011
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Liver Acute cholecystitis management Q.

51 y/o febrile (102) pt with +ve Murphy's sign

most appropriate management

A. Admit for next day surgery
B. IV antibiotics and observe
C. IV Fluids and observe
D. Urgent percutaneous drainage
E. Urgent surgical evaluation for immediate surgery
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  #2  
Old 05-13-2011
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The question should have more info, this is not enough to answer
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Old 05-13-2011
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If it was biliary colic, we'd give an antispasmodic and a NSAID to the patient.

But here in that case, the patient has an acute cholesistitis so the appropriate management is surgery as soon as possible. (In some conditions when the surgery couldn't be done due to some reasons, we should give the pt iv antibiotics, iv fluids and insert a nasogastric tube in case of an aspiration due to vomiting. So JaJeek is right, we should have more information about the pt.)

P.S. Sorry for my poor English=)
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Old 05-13-2011
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If this is a case of cholecystitis, surgery is apropriate ONLY within 72 hours from the onset of SYMPTOMS. In clinical practice, this is almost never the case, unless the patient is unstable and in very serious condition (and even in this case, surgery is an option of despair). What is more, fever may indicate cholangitis, in which case surgery would be catastrophic.


All in all, I would go for B (iv antibiotics & observation) PLUS NPO, to prevent biliary secretion and motility.
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Old 05-13-2011
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yup...B antibiotics followed by interval cholecystectomy
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Old 05-14-2011
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Default acute cholecystitis --> answer is B

for diagnosis: sonogram (thick walled gallbladder)
for management: NG suction, NPO, IV fluids, IV antibiotics then observe (give it time before ELECTIVE cholecystectomy can follow)

this ptt does not have (not mentioned) deteriorating vital signs or signs of need for IV fluids. so i'd go with B too. IV antibiotics and then observe. see if there is a need for ELECTIVE surgery later.
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Old 05-14-2011
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Default Ditto

Yes. Agree with fellows.

B.

Reasons ditto as others!
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Old 05-14-2011
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51 y/o male comes to emergency dept with pain UR Quadrant, fever 102, no medications or other medical problems. in ER Temp 101 , BP 130/70 , Pulse 90. .. (a description of murphy's sign) .

Wht is the most appropriate management?

ANS: Admit for next day surgery.


Even i answered B like most of you because my idea is that acute cholecystitis should be "cooled down " with Abx and fluids etc first... and then surgically removed. (kaplan surgery notes also says the same thing.. ) so was somewhat confused.

Sorry if the data appeared too less, so i descirbed the whole Q here. Thanks.
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  #9  
Old 05-14-2011
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http://www.merckmanuals.com/professi...030-ch030c-681

As i said before in my previous post, the surgery must be done asap.
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  #10  
Old 05-14-2011
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Default

Quote:
Originally Posted by Proxery View Post
http://www.merckmanuals.com/professi...030-ch030c-681

As i said before in my previous post, the surgery must be done asap.
dude thx for the link!! i love it.

however, i think answers in books can be wrong sometimes.

i read the link. its exactly what it says in KLN. IV antiobiotics and NPO first. WHEN the ptt is stable, we opt for surgery if needed. do u think this patient is stable with a temp of 101, pulse of 90 and heart rate of 130/70? isnt there a risk of surgery here?
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Old 05-14-2011
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Default

u know what, i think there might be some discrepancies in the question and or the answer.

i looked up MTB 3 and it says for acute cholecystitis:
NPO, NG suction, IV fluids and antibiotics. followed by elective cholecystectomy after 6-12 weeks.

emergency cholecystectomy is needed if there is signs of generalized peritonitis or emphysematous cholecystitis (is there??)...

also the answer chooses admit next day for surgery. NEXT DAY? what about now? we just look at the ptt?
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  #12  
Old 05-15-2011
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In this case, i think the best management is,

1 Stabilization of the pt with NPO, NG Suction IV fluids and antibiotics.

(I read in some book that the acute cholecystitis resolves in 80% of pts with the supportive care. So, if there is no signs of complications like peritonitis, the best option is to stabilize the pt and admit for the next day surgery or asap.)

2 Admit for next day surgery.

Quote:
Originally Posted by Seetal View Post

however, i think answers in books can be wrong sometimes.
Yes, i agree with that =)
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  #13  
Old 05-27-2011
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Thanks guys... this is the problem with step 2 CK questions.. step 1 questions u either know the answer or not - here you can know the answer and NOT know the answer same time.

Anyway, i think the consensus among the various books and documents is that surgery is definitely a part of the management of ACC and so are antibiotics. I hope in MLE there will be an answer with a combination Abx followed by Sx. And that would be the best one.

thanks all for the inputs.
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  #14  
Old 05-27-2011
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Quote:
Originally Posted by Seetal View Post
dude thx for the link!! i love it.

however, i think answers in books can be wrong sometimes.

i read the link. its exactly what it says in KLN. IV antiobiotics and NPO first. WHEN the ptt is stable, we opt for surgery if needed. do u think this patient is stable with a temp of 101, pulse of 90 and heart rate of 130/70? isnt there a risk of surgery here?
risk = nop, this is still an ASA physical status IE patient (not sign of severe sepsis or septic shock )

Best answer:
A. Admit for next day surgery

ref. from UpToDate 19.1:
"Antibiotics — Although acute cholecystitis is primarily an inflammatory process, secondary infection of the gallbladder can occur as a result of cystic duct obstruction and bile stasis.
It is not clear that antibiotics are required for the treatment of uncomplicated cholecystitis."
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