What is the appropriate workup and management for a patient presenting to the emergency department with abdominal pain, nausea, and vomiting 7 days postoperative from a cholecystectomy (gallbladder removal)?

Emergency Department Workup for Abdominal Pain, Nausea, and Vomiting 7 Days Post-Cholecystectomy

The emergency department workup for a patient with abdominal pain, nausea, and vomiting 7 days after cholecystectomy should prioritize ruling out bile duct injury through prompt laboratory assessment of liver function tests and abdominal triphasic CT imaging, followed by targeted management based on findings. 1

Initial Assessment

Clinical Evaluation

• Assess for alarm symptoms suggesting bile duct injury:
  • Fever
  • Persistent abdominal pain
  • Abdominal distention
  • Jaundice
  • Nausea and vomiting 2, 1

Laboratory Tests

• First-line laboratory tests:
  • Liver function tests (LFTs): direct and indirect bilirubin, AST, ALT, ALP, GGT, albumin
  • Complete blood count (CBC)
  • Pancreatic enzymes (amylase, lipase)
  • For critically ill patients: CRP, PCT, lactate to evaluate severity of inflammation/sepsis 2, 1

Imaging Studies

• Abdominal triphasic CT as first-line imaging to detect:
  • Intra-abdominal fluid collections
  • Ductal dilation
  • Signs of biliary leak or obstruction 2, 1
• Consider contrast-enhanced MRCP as second-line imaging for:
  • Exact visualization and classification of bile duct injuries
  • Planning tailored treatment 2, 1

Management Based on Findings

For Bile Leak or Biloma

1. If surgical drain is present with bile leak:

   • Initial observation and nonoperative management
   • Parenteral broad-spectrum antibiotics (piperacillin/tazobactam, imipenem/cilastatin, meropenem, ertapenem, or aztreonam) 2, 1

2. If no drain was placed:

   • Percutaneous drainage of collections
   • Antibiotic therapy for 5-7 days 2, 1

3. For persistent leaks:

   • Endoscopic management with ERCP, biliary sphincterotomy, and stent placement 1

For Biliary Stricture or Obstruction

• For minor biliary duct injuries (Strasberg A-D):

  • Nonoperative management with observation
  • ERCP with biliary sphincterotomy and stent placement if no improvement 1

• For major biliary duct injuries (Strasberg E1-E2):

  • Urgent referral to center with hepatopancreatobiliary expertise
  • Surgical repair with Roux-en-Y hepaticojejunostomy if diagnosed within 72 hours
  • If diagnosed between 72 hours and 3 weeks: percutaneous drainage, targeted antibiotics, and nutritional support 1

For Diffuse Biliary Peritonitis

• Urgent abdominal cavity lavage and drainage
• Broad-spectrum antibiotics
• Fluid resuscitation 2, 1

Symptomatic Management

Nausea and Vomiting Control

• Ondansetron 4mg IV is recommended for postoperative nausea and vomiting 3, 4
• Particularly effective in patients undergoing laparoscopic procedures 3, 5
• Alternative or additional options:
  • Dexamethasone (8mg) has shown effectiveness when combined with other antiemetics 4, 6
  • Metoclopramide can be used as an alternative 5

Pain Management

• Prefer oral administration of analgesics for moderate-to-severe pain
• Consider NSAIDs and COX-2 inhibitors as first-line agents
• Opioids for severe pain if needed 1

Important Considerations and Pitfalls

• Misclassification of injury severity can lead to inadequate treatment 1
• Delay in diagnosis and treatment of bile duct injuries increases morbidity and mortality 2, 1
• Non-referral to specialized centers can lead to poor outcomes in complex cases 1
• Hypothermia should be avoided at all costs in the postoperative setting 2
• Early mobilization is important for prevention of venous thromboembolism 2

Follow-up

• If symptoms resolve with initial management, follow-up with surgical team within 1-2 weeks
• If bile duct injury is identified, immediate referral to a center with hepatopancreatobiliary expertise 1
• For patients with biliary stents, follow-up ERCP for stent removal/exchange should be scheduled 1