NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Q: What is the most likely diagnosis? A: The patient most likely has acute cholecystitis with cholelithiasis (acute calculus chole- cystitis). Q: What is the next step? A: It is necessary to start antibiotics after obtaining blood cultures. Generally, antibiotics that cover gram-negative rods and anaerobes are warranted preoperatively and for 24 hours postoperatively in patients undergoing cholecystectomy. The most frequent or- ganism cultured from patients is Escherichia coli , followed by Enterobacter , Klebsiella , and Enterococcus . A second-generation cephalosporin is adequate for most high-risk cases. Most patients need intravenous (IV) resuscitation and are placed on nothing-by-mouth (NPO) feeding. A nasogastric (NG) tube may be necessary if they have persistent nausea or vomiting. Q: What course do you expect the patient to follow over the next 1–2 days? A: With antibiotics and fluids, the patient’s temperature will most likely return to normal. Her condition will improve. Q: What is your management plan? A: The patient should have a laparoscopic cholecystectomy at this presentation. The sur- gery is technically easier if done within 72 hours of symptom onset.

Case 7.4 Right Upper Quadrant Pain with Gallstones and Jaundice You admit a patient with symptomatic cholelithiasis. In addition to an elevated alkaline phosphatase and gallstones on ultrasound, the bilirubin is elevated at 4 mg/dL. Q: How does this finding change the proposed management plan? A: You should suspect common bile duct (CBD) obstruction when a patient presents with jaundice or has elevated liver enzymes. It is also necessary to determine whether the ultrasound shows dilated extrahepatic bile ducts, which is evidence for obstruction of the CBD. It is essential to clear the common duct of stones if they are present, either using ERCP preoperatively, or intraoperatively by CBD exploration and stone extraction. Management may involve several approaches. In the past, an open cholecystectomy with exploration of the CBD was more common. Currently, either of the following treat- ment plans is recommended: most commonly ERCP followed by laparoscopic chole- cystectomy. Other options include laparoscopic cholecystectomy with intraoperative cholangiogram and common duct exploration or laparoscopic cholecystectomy and postoperative ERCP (Fig. 7-4) . SAMPLE