Gastrointestinal · Year 2 · from Gastrointestinal
Case 2: Ascending Cholangitis
Patient Presentation
Demographics: 68-year-old male
Chief Complaint: Fever, jaundice, and right upper quadrant pain for 2 days
History of Present Illness: The patient developed fever with rigors, followed by right upper quadrant pain and progressive jaundice over 2 days. He has become increasingly confused. He had an ERCP 2 weeks ago for known common bile duct stones, but not all stones could be removed due to technical difficulty.
Past Medical History: Choledocholithiasis with prior incomplete stone removal, atrial fibrillation, hypertension
Physical Examination
- Vital Signs: Temperature 39.4C, BP 88/52 mmHg, HR 124 bpm, RR 24/min
- General: Toxic-appearing, jaundiced, confused male
- HEENT: Icteric sclerae
- Abdomen: Right upper quadrant tenderness, no peritoneal signs
- Neurologic: Disoriented to time and place
Workup and Results
- CBC: WBC 22,400 with bandemia
- Liver Function Tests: Total bilirubin 8.5 mg/dL, Direct bilirubin 6.8 mg/dL, ALP 485 U/L, GGT 380 U/L, AST 245 U/L, ALT 312 U/L
- BMP: Cr 2.1 mg/dL (baseline 0.9)
- Lactate: 4.8 mmol/L
- Blood Cultures: Drawn (later positive for E. coli)
- CT Abdomen: Dilated common bile duct (15 mm) with filling defect consistent with stone; pneumobilia from prior sphincterotomy
MRCP demonstrating a dilated common bile duct with filling defect (choledocholithiasis) causing biliary obstruction. In the clinical context of fever, RUQ pain, and jaundice (Charcot's triad), this indicates acute cholangitis.
Image Source: Case courtesy of Radiopaedia.org
Diagnosis
Acute Cholangitis - Severe (Reynold's Pentad present: Charcot's triad + hypotension + confusion)
Clinical Correlation
Acute cholangitis requires two elements: biliary obstruction AND bacterial infection. Obstruction (choledocholithiasis, stricture, malignancy) elevates intrabiliary pressure, disrupting the blood-bile barrier and allowing bacterial translocation into the bloodstream. Charcot's triad (fever, RUQ pain, jaundice) is present in 50-70% of patients. Reynold's pentad adds hypotension and altered mental status, indicating severe septic cholangitis. Common organisms include E. coli, Klebsiella, Enterococcus, and anaerobes. Tokyo Guidelines classify severity: Grade I responds to antibiotics; Grade II requires early drainage within 24 hours; Grade III (severe with organ dysfunction) requires emergency drainage within hours.
Treatment
- Emergent ICU admission
- Aggressive IV fluid resuscitation with vasopressors (norepinephrine)
- Broad-spectrum antibiotics: Piperacillin-tazobactam OR meropenem (cover biliary pathogens and possible resistant organisms)
- Emergency biliary drainage - ERCP with stone extraction/stent placement within hours
- If ERCP fails or unavailable: percutaneous transhepatic cholangiography with drainage
- Monitor for response: defervescence, improving hemodynamics
- Definitive stone clearance once stabilized (may require repeat ERCP or surgery)