Internal Medicine

0521779407-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:45

18 Acute Acalculous Cholecystitis Acute Bacterial Meningitis

management

What to Do First

■CT: best test to exclude other pathology

■If suspect biliary sepsis, radionuclide study first; otherwise, CT first

General Measures

■Blood cultures, IV broad-spectrum antibiotics

■Early recognition & intervention required due to rapid progression

to gangrene & perforation

specific therapy

■Cholecystectomy; both open & laparoscopic

■If evidence of perforation, then open cholecystectomy urgently;

inflammatory mass may preclude successful laparoscopy

■US-guided percutaneous cholecystostomy may be first choice in crit-

ically ill pts; success rate 90%; no surgery necessary if postdrainage

cholangiogram normal; catheter usually removed 6–8 wk

■Transpapillary endoscopic drainage of gallbladder may be done

when pt too sick for surgery & unsuitable for percutaneous drainage

(massive ascites or coagulopathy)

follow-up

■Routine postop follow-up

complications and prognosis

■<10% mortality in community-acquired cases

■Up to 90% in critically ill pts

Acute Bacterial Meningitis..............................

RICHARD A. JACOBS, MD, PhD

history & physical

History

■Increased risk with exposure to meningococcal meningitis or travel

to meningitis belt (sub-Saharan Africa), but most cases sporadic

■Increased incidence with extremes of age, head trauma, immuno-

suppression

Signs & Symptoms

■Prodromal upper respiratory tract infection progresses to stiff neck,

fever, headache, vomiting, lethargy, photophobia, rigors, weakness,

seizures (20–30%)