A 44-Year-Old Woman Is Brought to the Emergency Department with 2

question 61

Multiple Choice

A 44-year-old woman is brought to the emergency department with 2 days of abdominal pain.  She has had worsening upper abdominal pain associated with nausea and multiple episodes of non-bloody vomiting.  She also reports subjective fevers and chills.  The patient's past medical history is notable for hypertension.  She drinks alcohol socially and does not use tobacco or recreational drugs.  Her last drink was a week ago.
Temperature is 38.4 C (101.2 F) , blood pressure is 116/60 mm Hg, pulse is 112/min, and respirations are 18/min.  BMI is 34 kg/m².  Mucous membranes are dry and there is mild scleral icterus.  There is tenderness in the mid-epigastrium and right upper quadrant without rebound or guarding.  Rectal examination is notable for brown guaiac-negative stool.
Laboratory results are as follows:

CT scan of the abdomen shows diffuse pancreatic enlargement and heterogenous attenuation with peripancreatic inflammation.  The liver appears normal.  The gallbladder has multiple small gallstones with surrounding gallbladder wall edema.  The common bile duct is dilated and measures 12 mm.
The patient is made NPO and is started on analgesics, intravenous hydration, and empiric intravenous antibiotics.
Which of the following is the most appropriate next step in management of this patient?

• A)Continue current management and observe closely
• B)CT-guided percutaneous pancreatic aspiration
• C)Endoscopic retrograde cholangiopancreatography
• D)Hepatobiliary iminodiacetic acid (HIDA) scan
• E)Surgical evaluation for cholecystectomy