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A 63-Year-Old Man Comes to the Emergency Department Due to Worsening

Question 375
Multiple Choice
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Multiple Choice

A 63-year-old man comes to the emergency department due to worsening pain in the right upper quadrant, nausea, and vomiting since last night.  He woke up at midnight with abdominal discomfort and nausea.  He could not fall back to sleep due to the increasing pain as well as malaise and shaking chills.  The patient had 2 episodes of vomiting this morning.  He has gastroesophageal reflux disease and takes esomeprazole occasionally.  He also has a history of hypertension and osteoarthritis.  The patient drinks a glass of wine daily with dinner but does not use tobacco or illicit drugs.  On initial evaluation, he appears uncomfortable due to pain.  Temperature is 38.3 C (101 F), blood pressure is 96/65 mm Hg, pulse is 102/min and regular, and respirations are 18/min.  Physical examination shows mild scleral icterus.  Mucous membranes are dry.  The abdomen is soft and nondistended, with moderate tenderness in the right upper quadrant.  There is no rebound tenderness.  Bowel sounds are active.  Laboratory results are as follows: img Serum creatinine is 0.9 mg/dL.  Abdominal ultrasonography reveals increased liver echotexture consistent with fatty infiltration, several small gallstones, and dilated biliary ducts.  Intravenous fluids and empiric antibiotics are administered, and the blood pressure and tachycardia improve.  Which of the following is the best management strategy for this patient?

A)Conservative therapy with narrowing of antibiotics and close observation only
B)Elective laparoscopic cholecystectomy in 4-6 weeks
C)Endoscopic retrograde cholangiopancreatography
D)Laparoscopic cholecystectomy within 72 hours of admission
E)Open cholecystectomy and biliary drainage

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