[size=20px]A 7 year-old girl with sickle cell disease presents to the emergency department with 3 days of right upper quadrant pain. Laboratory investigations are significant for a total bilirubin of 2.9 mg/dL and direct bilirubin of 2.5 mg/dL. Lipase and liver enzymes are normal. Abdominal ultrasound is significant for cholelithiasis and pericholecystic fluid. The CBD is within normal limits and there is no intrahepatic duct dilatation. What is the best next step in the management of this patient?

 

A Laparoscopic cholecystectomy only

 

B Laparoscopic cholecystectomy with post-operative bilirubin trend

 

C MRCP followed by laparoscopic cholecystectomy

 

D Laparoscopic cholecystectomy with intraoperative cholangiogram (IOC)

 

E Pre-operative ERCP followed by laparoscopic cholecystectomy[/size]

D

E

Edited July 3, 20224 yr by Ismailmohamed

correct answer

D Laparoscopic cholecystectomy with intraoperative cholangiogram (IOC)

 

This patient has an intermediate risk for choledocholithiasis and therefore should undergo a laparoscopic cholecystectomy and IOC. By performing an IOC, the need for a second procedure may be avoided, which is especially important in children. MRCP is a reasonable option but should be avoided when possible because it is associated with increased costs, length of stay, and may require sedation in younger patients.