A 35-year-old otherwise healthy female status post Roux-en-Y gastric bypass surgery presents to the ICU with abdominal pain mainly in the epigastric region with temperature of 101.5°F, blood pressure of 84/60 mm Hg with altered mental status after 4 L of crystalloid in the ED. A CT scan that does not demonstrate any bowel obstruction or internal hernia however a mildly dilated common bile duct with gallstones is visualized without signs of cholecystitis. On examination, she is jaundiced with epigastric tenderness to palpation. She has a slight elevation in her AST and ALT and direct bilirubin of 5 mg/dL. Aside from appropriate intensive care resuscitation, what is the next BEST step in the management of this patient?
A. IV antibiotics and emergent surgical and gastroenterology consultationCorrect Answer: A
Acute cholangitis should be suspected in patients with fever, abdominal pain, and jaundice (Charcot triad) and abnormal liver enzyme tests with signs of obstructive jaundice. This patient already has a CT scan that shows a mildly dilated common bile duct. CT imaging has a high sensitivity for bile duct dilation but low sensitivity for bile duct stones. A follow-up ultrasound is not necessary for this patient. Abdominal ultrasound has a high specificity for bile duct dilation and bile duct stones but variable sensitivity for bile duct dilation and bile duct stones. In a patient with Charcot triad and elevated liver enzymes with a normal CT scan and/or ultrasound, and MRCP is ordered with a higher diagnostic accuracy in identifying causes of biliary obstruction. However, this patient has evidence of Reynold Pentad defined by Charcot triad along with signs of end organ dysfunction such as altered mental status and hypotension consistent with signs of severe cholangitis. Patients with mild and moderate cholangitis generally respond well to early antibiotic therapy and biliary decompression within 24 to 48 hours. Patients with mild to moderate cholangitis who fail to respond to conservative management within 24 hours or those patients with severe (suppurative) cholangitis require biliary decompression urgently (within 24 hours). Endoscopic sphincterotomy with stone extraction and/or stent insertion is the treatment of choice. Endoscopic decompression is successful in 90% to 95% of patients after sphincterotomy. Endoscopic drainage has a significantly improved mortality and morbidity compared to surgical decompression. Percutaneous transhepatic biliary drainage can be performed when ERCP is unavailable or unsuccessful. Surgical decompression is used in patients whom ERCP and drainage have failed. Laparoscopic or open common bile duct exploration with decompression with or without placement of T-tube is the surgical choice. In this patient who is showing signs of hemodynamic instability and end organ dysfunction, both the surgical team and gastrointestinal team should get involved urgently. CT head is not the next best step as this patient’s clinical examination, imaging, and laboratory test results support cholangitis as the reason for the altered mental status with no lateralizing symptoms.
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