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CASE SCENARIOS

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Case 1

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A 45-year-old obese woman presents to the emergency department with a 1-day history of constant right-sided abdominal pain. She has had similar episodes before; however, in prior instances the pain was self-limited and subsided within hours. She also reports nausea, vomiting, and low-grade fevers at home. Her medical history includes 4 prior cesarean sections.

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On examination, she appears mildly uncomfortable with pulse of 85 beats per minute, blood pressure 140/95 mm Hg, and temperature of 100.8°F. Her abdomen is soft and nondistended, with focal right upper quadrant (RUQ) tenderness. Her labs reveal a white blood cell (WBC) count of 12,000, a total and direct bilirubin of 1.2 and 1.1, with an alkaline phosphatase (AP) of 98 and normal aspartate aminotransferase (AST) and alanine aminotransferase (ALT).

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Case 2

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The medical intensive care unit (ICU) team requests a consult for a 70-year-old man hospitalized for 2 weeks with pneumonia. He has been intubated and sedated since hospital day 2, is on 2 vasopressors, and has been on total parenteral nutrition (TPN) for 7 days. His medical history includes diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. On physical examination, his abdomen is soft and mildly distended, and a mass is appreciable in the RUQ. He appears jaundiced. His most recent respiratory cultures have been negative, but he continues to have fevers to 101°F and a persistent leukocytosis, with a WBC ranging from 12,000 to 16,000. He also has mildly elevated liver function tests, with total bilirubin of 2.5, AP of 200, AST of 65, and ALT of 82.

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Case 3

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A 65-year-old man presents to the emergency department with a 2-day history of right-sided abdominal pain. He reports that the pain is constant and has gradually worsened. He is also complaining of nausea, vomiting, and fevers. His medical history is significant for diabetes mellitus and hypertension.

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On examination, patient is ill appearing and is noted to have a temperature of 101.4°F, heart rate of 105 beats per minute, and blood pressure of 135/95 mm Hg. His abdominal examination is significant for RUQ tenderness to palpation with associated crepitus. Pertinent labs include a leukocytosis of 14,000/cc, elevated total bilirubin of 2.3 mg/dL, and indirect bilirubin of 1.7 mg/dL.

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EPIDEMIOLOGY

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Cholecystitis is one of the most common diagnoses encountered by general surgeons. In the United States, 10% to 15% of adults have gallstones, and 1% to 4% of these patients become symptomatic each year.1 Gallstones are either cholesterol or pigment based. Risk factors for developing cholesterol stones include female gender (especially women who have had multiple pregnancies), obesity, rapid weight loss, elevated serum triglyceride levels, Western diet (high fat and low fiber), and diabetes.2 Pigment stones tend to develop after prolonged fasting, TPN use, ileal resection, vagotomy, hemolytic states, cirrhosis, ...

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