What is the next step in management for a patient with a PEG (Percutaneous Endoscopic Gastrostomy) tube site infection, improved symptoms on topical and G-tube medications, and abnormal abdominal ultrasound findings including a possible gallstone or polyp and thickened right renal cortex?

Management of PEG Site Infection with Incidental Ultrasound Findings

Continue current local wound care for the improving PEG site infection, verify G-tube placement with the ordered abdominal X-ray, and arrange follow-up ultrasound in 3-6 months for the gallbladder polyp/stone while monitoring the thickened right renal cortex with basic renal function tests. 1, 2

PEG Site Infection Management

Current Treatment Assessment

• The improving erythema and drainage with topical antimicrobials and G-tube medications indicates appropriate initial management. 1, 2
• Continue cleaning the stoma site at least once daily with an antimicrobial cleanser. 1, 2
• Maintain application of zinc oxide or barrier cream to protect surrounding skin from gastric drainage. 3
• Use foam dressings rather than gauze, as foam lifts drainage away from the skin and reduces maceration. 3

Monitoring for Treatment Failure

• If the infection does not continue to resolve within 5-7 days total, escalate to oral broad-spectrum antibiotics. 3, 1
• Watch for systemic signs (fever, peritonitis) that would require intravenous antibiotics and possible surgical intervention. 3, 1
• Verify proper external bolster tension with approximately 1 cm of play between the skin and bolster to prevent ongoing complications. 3, 1

G-Tube Placement Verification

• The ordered abdominal X-ray is appropriate to confirm proper tube positioning, especially given the recent infection. 3
• This will also evaluate for any acute intra-abdominal abnormalities that could complicate the infection. 3

Gallbladder Polyp/Stone Management

Risk Stratification

• Small gallbladder polyps (<10 mm) have benign natural history with minimal malignant potential and require only surveillance. 4, 5, 6, 7, 8
• The ultrasound finding of "gallstone versus polyp" requires differentiation, but management is similar for small lesions. 4, 5
• Malignancy risk factors include: size >10 mm, age >50 years, solitary lesions, sessile morphology, and concurrent gallstones. 4, 5, 7

Surveillance Strategy

• Arrange repeat ultrasound in 3-6 months to characterize the lesion and establish baseline for comparison. 4, 5, 7
• If the lesion is confirmed as a polyp <10 mm and the patient remains asymptomatic, continue surveillance ultrasonography at 6-12 month intervals initially. 4, 5, 6, 7
• No intervention is needed unless the patient develops biliary symptoms, the polyp grows to >10 mm, or demonstrates rapid growth. 4, 5, 7

Indications for Cholecystectomy

• Polyps >10 mm diameter require cholecystectomy due to malignancy risk (34-88%). 4, 5, 7
• Other surgical indications include: symptomatic biliary pain, rapid growth, sessile morphology, age >50 with other risk factors, or abnormal gallbladder wall. 4, 5, 7

Thickened Right Renal Cortex

Initial Evaluation

• Obtain basic renal function tests (creatinine, BUN, eGFR) and urinalysis to assess for underlying renal disease. [General Medicine Knowledge]
• Review the patient's medical history for hypertension, diabetes, or chronic kidney disease risk factors. [General Medicine Knowledge]
• The left kidney was not visualized due to positioning, so clinical correlation with renal function is essential. [General Medicine Knowledge]

Follow-up Imaging

• If renal function is abnormal or the patient has risk factors for renal disease, consider dedicated renal ultrasound with Doppler or CT to better characterize the cortical thickening. [General Medicine Knowledge]
• If renal function is normal and the patient is asymptomatic, repeat imaging can be deferred or combined with the follow-up gallbladder ultrasound in 3-6 months. [General Medicine Knowledge]

Critical Pitfalls to Avoid

• Do not use topical antibiotics on the PEG site, as they promote antimicrobial resistance; use antimicrobial ointments or sustained-release dressings instead. 9, 2
• Do not pursue cholecystectomy for small gallbladder polyps without clear indications, as 90% remain static and benign. 6, 7, 8
• Do not ignore the incomplete ultrasound (CBD and left kidney not visualized); if clinical suspicion for pathology exists, obtain dedicated imaging. [General Medicine Knowledge]
• Ensure the external bolster is not too tight, as excessive pressure increases infection risk and can cause tissue necrosis. 3, 1, 9
• Monitor for fungal superinfection at the PEG site, which may accompany bacterial infection and requires topical antifungal treatment. 3