Chapter 48

Question 1

What are the differential diagnosis for right upper quadrant abdominal pain?

Answer 1

Biliary colic, acute cholecystitis, a cute peptic ulcer perforation acute pancreatitis acute hepatitis liver abscess lower lobe pneumonia and pyelonephritis

Question 2

What is the physical examination for this patient?

Answer 2

Guarding and tenderness upon palpation of RUQ. Inspiratory rest with palpation of RUQ

Question 3

What should be done to increase diagnostic accuracy and illuminate other alternative diagnosis in a patient with acute cholecystitis?

Answer 3

CBC, BMP, LFT, serum amylase and lipase, blood cultures, abdominal plain film, abdominal ultrasound, bowel rest, analgesics, empiric antibiotics

Question 4

What should be done after confirmation with ultrasound?

Answer 4

Consultation with general surgery, standard pre-op orders and close monitoring

Question 5

After consultation and 48 hours of supportive therapy with clinical improvement what should be ordered?

Answer 5

Laparoscopic cholecystectomy

Question 6

After the initial work up and the confirmation of a cholecystitis patient should be admitted and what should be their supportive medical therapy?

Answer 6

Bowel rest (NPO, IV fluids and NG tube if patient is vomiting).
Analgesics [NSAIDS (IM ketorolac), alternatives include opioids (butorphanol)]
IV empiric antibiotics against gram-negative and anaerobic (piptazo ticarcillin-clavu Third and metro)

Question 7

What is a definitive therapy for acute cholecystitis?

Answer 7

Surgery and the procedure of choice is Laparoscopic cholecystectomy

Question 8

How should the surgical risk dictate surgery for low surgical risk patients?

Answer 8

If clinical improvement then elective cholecystectomy during same hospitalization admission. If clinical deterioration and then emergent cholecystectomy

Question 9

Before surgery what should be done for all patients?

Answer 9

Assess surgical risk and closing manager condition for 24 to 48 hours

Question 10

How should the surgical risk dictate surgery for high surgical risk patients?

Answer 10

If clinical improvement then discharge and refer to non-surgical gallstone therapy.
If clinical deterioration then percutaneous cholecystectomy

Question 11

What does a preop work up include?

Answer 11

PT/INR, PTT

Question 12

When his discharge possible?

Answer 12

One or two days after surgery

Question 13

What should be done when the patient improves and becomes afebrile?

Answer 13

Laparoscopic cholecystectomy, routine