Internal Medicine · Year 3 · from Internal Medicine
Case 2: Sepsis with Multi-Organ Dysfunction
Patient Presentation
A 62-year-old man with a history of alcohol use disorder presents with 3 days of right upper quadrant pain, fever, and jaundice. He reports rigors and appears quite ill. He has not seen a doctor in years and has no prior abdominal surgery.
Vital Signs
- Blood Pressure: 78/45 mmHg
- Heart Rate: 122 bpm
- Respiratory Rate: 28/min
- Oxygen Saturation: 91% on room air
- Temperature: 39.8°C
Physical Examination
- General: Toxic-appearing, icteric, diaphoretic
- Cardiovascular: Tachycardic, cool and mottled extremities
- Pulmonary: Tachypneic, bibasilar crackles
- Abdomen: RUQ tenderness with voluntary guarding, positive Murphy's sign
- Skin: Jaundiced, mottled lower extremities
Laboratory Results
- WBC: 24,500/μL with 30% bands
- Hemoglobin: 11.2 g/dL
- Platelets: 68,000/μL
- Creatinine: 3.1 mg/dL (baseline unknown)
- Total bilirubin: 8.4 mg/dL
- AST/ALT: 180/210 U/L
- Alkaline phosphatase: 420 U/L
- Lactate: 6.8 mmol/L
- INR: 1.8
- ABG: pH 7.28, PaCO2 28, PaO2 68
Imaging
- RUQ ultrasound: Dilated common bile duct (12 mm), gallstones, gallbladder wall thickening
Clinical Image
Figure 2: Right upper quadrant ultrasound demonstrating dilated common bile duct with shadowing gallstones, consistent with choledocholithiasis causing acute cholangitis.
Image Source: Educational illustration for teaching purposes.
Questions
- What is Charcot's triad and what additional findings suggest Reynolds' pentad?
- A) Fever, jaundice, RUQ pain; add hypotension and altered mental status
- B) Fever, jaundice, tachycardia
- C) RUQ pain, nausea, vomiting
- D) Elevated bilirubin, elevated ALP, dilated CBD
- Calculate this patient's SOFA score based on available data.
- A) 4
- B) 8
- C) 12
- D) Cannot calculate
- What is the definitive treatment for acute cholangitis?
- A) Antibiotics alone
- B) Biliary decompression (ERCP or PTC) plus antibiotics
- C) Cholecystectomy
- D) Conservative management
- How should vasopressor therapy be initiated in septic shock?
- What is the significance of the elevated lactate and how should it guide management?
Answers
- A) Fever, jaundice, RUQ pain; add hypotension and altered mental status - Charcot's triad (fever, jaundice, RUQ pain) suggests cholangitis. Reynolds' pentad adds hypotension and altered mental status, indicating severe/suppurative cholangitis with high mortality requiring emergent intervention.
- Approximate SOFA score calculation (varies by exact parameters):
- Respiratory (PaO2/FiO2 ~324 on RA): 0-1 points
- Coagulation (platelets 68K): 2 points
- Liver (bilirubin 8.4): 2 points
- Cardiovascular (MAP <70, requiring pressors): 3-4 points
- CNS (potentially altered): 1-2 points
- Renal (Cr 3.1): 2 points
- Estimated total: 10-13 points - indicates severe organ dysfunction
- B) Biliary decompression (ERCP or PTC) plus antibiotics - Acute cholangitis requires:
- Source control through biliary drainage (ERCP with sphincterotomy preferred)
- Emergent drainage (<24 hours) for severe cholangitis
- Broad-spectrum antibiotics covering enteric gram-negatives and anaerobes
- PTC (percutaneous transhepatic cholangiography) if ERCP fails or unavailable
- Vasopressor initiation in septic shock:
- Start vasopressors if MAP <65 despite fluid resuscitation (or during resuscitation if severe hypotension)
- Norepinephrine is first-line vasopressor
- Target MAP ≥65 mmHg
- Add vasopressin (up to 0.03-0.04 units/min) as second agent if refractory
- Add epinephrine or dobutamine if cardiac dysfunction present
- Consider hydrocortisone 200 mg/day if vasopressor requirements are high or increasing
- Significance of elevated lactate:
- Lactate >2 mmol/L indicates tissue hypoperfusion
- Lactate >4 mmol/L associated with significantly increased mortality
- Serial lactate measurements guide resuscitation adequacy
- Target: Normalization of lactate (or >10% decrease per 2 hours)
- Persistent elevation despite treatment suggests ongoing shock or inadequate source control
- This patient's lactate of 6.8 indicates severe tissue hypoperfusion