Case 6: Management

Here is a representative image of the RUQ Ultrasound findings:

The ultrasound findings are diagnostic for acute calculous cholecystitis. Biliary dilation was also noted.

What would you estimate his likelihood to have concomitant choledocholithiasis to be?
Correct! See below the characteristics used to determine likelihood of choledocholithiasis.




Choose the next best steps in management (hint: multiple choices might be correct). 
Supportive care, including pain management with NSAIDs
Incorrect. Try again!

Emergent cholecystectomy
Incorrect. This would be indicated if the patient developed symptoms of complications such as gallbladder gangrene/necrosis, perforation, or emphysematous cholecystitis. For our patient the more immediate step would be clearing the biliary tree to allow for drainage and prevent worsening jaundice or the development of cholangitis. Try again!

Antibiotic therapy
Correct! Common first line antibiotics for cholecystitis include amoxicillin-clavulanate, cephalexin plus metronidazole, or fluoroquinolone plus metronidazole.

Endoscopic Ultrasound (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
Correct! EUS is the most sensitive imaging modality to detect CBD stones and other hepatobiliary pathology that can cause biliary obstruction such as CBD strictures and cholangiocarcinoma. During the ERCP the biliary tree can be explored, sludge and stones can be removed, strictures or masses can be biopsied, and a biliary stent can be placed to facilitate drainage.

Mechanical lithotripsy
Incorrect. This would not be the first line of treatment in these cases. Try again!

Magnetic Resonance Cholangiopancreatography (MRCP)
Incorrect. In a patient with strong predictors for choledocholithiasis the cost-conscious management plan would be to directly proceed with EUS/ERCP which can provide diagnostic confirmation in addition to the opportunity to therapeutically intervene. In cases where likelihood of choledocholithiasis is lower, or when other biliary pathology such as strictures or cholangiocarcinoma are strongly considered, MRCP would be useful. Try again!

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Case 6 Index:
Physical Exam
Differential Diagnosis
Diagnostic Testing

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