A 45-year-old female with a past medical history of obesity and cholelithiasis presents to the emergency department with 2 days of right upper quadrant abdominal pain, fevers, and emesis. She is febrile to 102°F and her systolic blood pressure in the 80s mm Hg. Her systolic blood pressure improves to the 100s with 2 L lactated ringers. Her laboratory test results are notable for a WBC count of 19,000/mm3 (85% neutrophils), total bilirubin 6 mg/dL, and amylase 130 U/L. An abdominal ultrasound is obtained in the emergency department that shows cholelithiasis, a common bile duct measuring 8 mm and an otherwise normal gallbladder. In addition to continued resuscitation with IV fluids, what is the most appropriate next step in management?
A. Laparoscopic cholecystectomyCorrect Answer: D
Acute cholangitis, or ascending cholangitis, is the result of stasis and subsequent infection of the biliary tract typically due to mechanical obstruction. The most common etiology of obstruction is biliary calculi, although other causes include benign and malignant strictures and biliary stent obstruction. Charcot triad of fever, abdominal pain, and jaundice is the classic presentation, with the addition of hypotension and altered mental status forming Reynold Pentad, which is indicative of more severe cholangitis with associated septic shock. Diagnosis is made with a high clinical suspicion, laboratory values including a leukocytosis with neutrophil predominance and a cholestatic pattern of liver tests (predominantly conjugated bilirubinemia) and imaging with biliary ductal dilatation or visualization of the underlying cause of obstruction. Imaging modalities include ultrasound, computed tomography, or magnetic resonance cholangiopancreatography. In addition to resuscitation with isotonic crystalloid solution and initiation of antibiotic therapy, it is important to address the need for biliary ductal decompression or resolution of persistent biliary obstruction. In the patient above presenting with acute cholangitis and concerns for persistent biliary obstruction (total bilirubin 6 mg/dL, common bile duct measuring 8 mm) antibiotics alone will not be sufficient. Although a percutaneous cholecystostomy tube will aid in decompression of the biliary tree, it does not address the distal common bile duct obstruction and therefore is not the best first line option. Given that the patient’s cholangitis is likely due to choledocholithiasis (gallstones obstructing the common bile duct), she may eventually benefit from a cholecystectomy to prevent recurrent episodes of choledocholithiasis, but cholecystectomy at this time will not address her ongoing bile duct obstruction. Although percutaneous transhepatic cholangiography performed by Interventional Radiology decompresses the biliary tree and may be able to address more distal obstructions, it is a technically difficult procedure that typically requires intrahepatic ductal dilatation and is not currently first line therapy when a gastroenterologist is available to perform endoscopic retrograde cholangiopancreatography and the patient’s anatomy is amenable to it.
References: