A 63-year-old woman with a history of hypertension and dyslipidemia presents to the emergency department with severe right upper quadrant pain. On examination, she is grimacing and agitated with notable jaundice. She is oriented to self only. She has right upper abdominal tenderness, but no peritoneal signs. Vital signs include:
Pertinent laboratory test results include:
Blood cultures are pending. An ultrasound performed at bedside shows biliary dilation.
Appropriate initial management includes which of the following:
A. Admission to the general surgical wardCorrect Answer: D
Severe acute cholangitis is a life-threatening condition caused by biliary obstruction complicated by infection of the biliary tree. Many patients present with Charcot’s triad of right upper quadrant abdominal pain, fever, and jaundice. In cases of severe (suppurative) cholangitis, patients may also have hypotension and altered mental status, which make up Reynold’s pentad. Any type of biliary obstruction can lead to acute cholangitis, but biliary calculi are the most common cause. Other causes include benign or malignant biliary stricture and biliary stent obstruction. Enteric bacteria are the most common culprit, and 20% to 80% of patients will have bacteremia. Gram-negative rods such as E. coli and Klebsiella are often cultured, but gram-positive cocci and anaerobes are not unusual.
The diagnosis of acute cholangitis can be difficult; many patients have a more subtle presentation than this case. Updated Tokyo guidelines for definitive diagnosis include the presence of three criteria: (1) systemic inflammation (fever, leukocytosis, leukopenia, or elevated C-reactive protein, (2) cholestasis (jaundice or liver function tests >1.5 times upper limit of normal), and (3) imaging findings (biliary dilation or evidence of the cause of biliary obstruction on imaging). There are many imaging choices, but ERCP is the most sensitive and has the added benefit of treating the cholangitis through decompression of the biliary tree. However, given the risk associated with sedation/anesthesia for this procedure, noninvasive imaging is usually performed first. Management is focused on treating the infection and relieving obstruction. First steps include rehydration with IV fluids, correction of electrolyte abnormalities and coagulopathy, and broad spectrum antibiotics. Frequently recommended first-line antibiotic regimens include piperacillin/tazobactam or a third- or fourth-generation cephalosporin.
Patients with severe acute cholangitis such as this one should be monitored in the ICU because they are at risk for rapid clinical deterioration and mortality is high. Patients managed only conservatively have a mortality approaching 100%, so the next step is biliary decompression, with ERCP preferred over surgery. ERCP has a success rate of 98% and a much lower complication rate compared to surgical decompression. Surgical drainage is now rarely performed because of a very high risk of complications (∼66%) and a mortality rate >30%.
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