NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Q: How would you evaluate and manage the following situations?

Case Variation 7.8.1. A temperature of 104°F, a BP of 90/60 mm Hg, and a WBC count of 20,000/mm 3 ◆ ◆ This patient may have acute biliary sepsis and needs emergent evaluation, antibiotics, and resuscitation. Possible diagnoses include empyema of the gallbladder, CBD obstruction with cholangitis, and liver abscess, among others. It is necessary to establish a diagnosis and institute definitive therapy. An ultrasound is the first diagnostic test. If the cause is biliary in nature, urgent drainage or surgery is essential in most cases. Case Variation 7.8.2. A temperature of 96°F and a WBC count of 3,900/mm 3 ◆ ◆ The patient should be treated in a similar manner as previously described in Case Variation 7.8.1. Remember, elderly patients can manifest signs of sepsis with hypother- mia or leukopenia. Case Variation 7.8.3. A tender 3-cm-diameter palpable mass in the RUQ, a temperature of 103°F, and mental obtundation ◆ ◆ This mass is most likely an inflamed gallbladder with omentum attached to the gallbladder that “walls it off.” When the gallbladder is palpable, typically in sick elderly patients, many surgeons term the condition a “palpable gallbladder.” The implication is that an emergent cholecystectomy is necessary as soon as resuscitation occurs because there is a high risk of gallbladder rupture, which carries a highmortality. The mental obtundation is a sign of sepsis. ◆ ◆ If the patient is too sick to undergo surgery, then the gallbladder can be drained via percu- taneous radiologic guidance or with a small cut down under local anesthesia. Some similar older patients have air in the wall of the gallbladder, which indicates that a gas-forming organism has invaded the tissues. This is obviously a serious complication and requires urgent surgery. It is termed an emphysematous gallbladder .

Case 7.9 Right Upper Quadrant Pain, Fever, and Jaundice You are asked to see a 51-year-old who presented to the emergency department with recent onset of jaundice (bilirubin, 9 mg/dL), fever, and RUQ pain and tenderness. A: Pancreatic cancer is very unlikely. Biliary sepsis does not usually develop in patients with pancreatic cancer. Patients present with abdominal or back pain, weight loss, and jaundice. SAMPLE Q: What is the most likely diagnosis? A: The condition most likely is acute cholangitis . Q: What are the basic steps in the patient’s initial evaluation? A: The basic steps in initial evaluation are resuscitation, antibiotics, and an urgent ultra- sound study of the biliary tree . If obstruction or dilation of the CBD is seen, then ERCP and biliary decompression are warranted. Q: What is the likelihood that this patient has pancreatic cancer with distal bile duct obstruction?