MEDizzy - A 49-year-old, obese man presents to the emergency room with

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The Biliary Tract

A 49-year-old, obese man presents to the emergency room with a 24-hour history of fever, chills, and abdominal pain. He describes crampy pain in the midepigastric region with radiation to the right shoulder. He also reports some associated nausea and vomiting. His vital signs include: temperature, 38.9° C; blood pressure, 156/96 mm Hg; pulse, 99/min; and respiration, 16/min. His sclera are anicteric, his heart is regular, and his lungs are clear to auscultation except for occasional wheezes. Laboratory results include: white blood cells = 14,000; hematocrit = 42; platelets = 221; Na + = 132; K+ = 3.3; Cl = 100; CO2 = 21; blood urea nitrogen = 20; creatinine = 1.5; glucose = 266; total bilirubin = 1.2; conjugated bilirubin = 0.1; alkaline phosphatase = 242; and amylase = 30. A right upper quadrant (RUQ) ultrasound was attempted but because of the patient's size the gallbladder could not be adequately visualized. Which of the following is the most appropriate next step in the management of this patient?

ExplanationB. This patient has a presentation that is highly suggestive of acute cholecystitis. When a right upper quadrant (RUQ) ultrasound is equivocal, the next test of choice is nuclear imaging of the biliary tree, such as a HIDA scan. An oral cholecystogram can give the same information as the HIDA scan but it is much more time-consuming and the reliability is lower owing to the patient's vomiting. Cholangiography is not indicated before the HIDA scan but may be necessary if common duct obstruction is diagnosed. Surgery may be necessary, but not before confirming the diagnosis in this setting.