Acute Cholangitis

Case: You are an HMO in the ED and a 55-years-old male was brought in by ambulance complaining of severe upper
abdominal pain, fever, and jaundice for the last 2 days.

Task
a. History (RUQ pain worse with breathing, no relieving factor, 1st episode, + nausea, no travel history, SOB, shaking,
yellowing of skin x 2 days, no itching or change in color of urine or bowels)
b. Physical examination (ill, dehydrated, moderate jaundice, T: 38.2, tachycardia, tachypnea, chest clear, no pleural
rub, abdomen no scars or deformity, tenderness on RUQ on superficial or deep palpation, Murphy sign negative,
urine dipstick pending)
c. Investigations FBE (WBC increased with left shift), ESR/CRP, LFTs (bilirubin increased, conjugated
hyperbilirubinemia, AST/ALT raised), USD (liver is normal, stone in common bile duct)
d. Diagnosis and management

Case 2: Joseph aged 45 years was brought into your surgery by his wife Julia. Joseph had upper abdominal pain for a few
day associated with nausea, feeling unwell and tiredness. He also had fever and this AM had shakes with fever. Julia tells
you he was looking very unwell and seeks your help. Joseph lives at home with his wife and two children. He had no
significant medical or any surgical problems in the past. He is not on any regular medications. He is an occasional smoker
but drinks alcohol every evening.

Task
a. Further history (RUQ pain, severe, 3-4 SD per day;)
b. Physical examination (jaundice, 120 regular, 100/70, T: 38.5, RR 16, O2 97%)
c. Investigations
d. Probable diagnosis and management

History
- Please tell me more about the pain? Where is it? How bad is the pain? Can you point with one finger? Does
anything relieve or aggravate it? Does it go anywhere (back, tummy)? Do you think it is getting worse? Any
associated N/V? SOB? Chest pain? Cough? Palpitation?
- Fever? Since when? How high is it? Did you take any medications? Did it help?
- Please tell me more about the discoloration of your skin? When did it start? How did it start? Any associated
change in the color of your urine or stool (urine dark, stool pale)? Have you noticed itchiness anywhere else in the
body? Diarrhea? Constipation? Have you noticed any relationship of food with this pain? Is this the first episode?
Any previous similar complaints of fever and jaundice with pain?
- Did you travel recently? Did you come into contact with a person with similar symptoms? What is your occupation?
Any chance of contact with blood products? Have you had blood transfusions previously? Any surgeries? Any
illnesses in the past? Were you ever diagnosed with gallstones or liver disease? Have you noticed any changes to
your weight? Appetite? Lumps or bumps? Night sweats? SADMA? Any chance of needle sharing? Have you had
tattooing over the body? Are you on any medications at the moment? Any FHx of liver disease or gallstone
disease?

Physical examination
- General appearance: ill and septic? Degree of jaundice? Dehydration? Stigmata of liver disease
- Vital signs
- Lymph nodes
- Chest: auscultate for any added sounds, pleural rub
- Abdomen: distention, tenderness on palpation, Murphy sign, organomegaly
- DRE
- Urine dipstick and BSL

Differential Diagnosis
- Acute cholangitis: RUQ pain + fever and chills + jaundice
- Acute cholecystitis
- Acute hepatitis
- Choledocholithiasis
- Right lobar Pneumonia

Investigation
 - FBE, ESR/CRP, LFTs, USD of abdomen, CXR, blood culture, lipase/amylase

Diagnosis and Management

- From the history, examination and investigations that were provided to me, you most likely have a condition called
acute cholangitis. As you know, our liver is supposed to make certain substances that help with digestion. These
substances are stored in the gallbladder. Sometimes, due to certain causes like high blood cholesterol level,
hemolytic conditions, and genetic tendencies, there are stones that form within the gallbladder. Sometimes, these
stones start traveling into the draining ducts that we call as CBD. Very often, the stone gets stuck causing irritation
and inflammation of the lining of the bile duct. This gives symptoms like pain, jaundice, along with high-grade fever
like you have.
- This condition can be serious because of the risk of complications which are:
o Obstruction of CBD
o Septicemia (spread of infection to the blood)
o Stone may pass into the small bowel causing gallstone ileus (problems with motility of bowel)
o Rarely, liver and pancreas may become inflamed causing further complications
- At the moment, we will need to admit you. I will call in the surgical registrar to come and see you. We will start you
on IV fluids along with antibiotics (Ceftriaxone + Metronidazole or triple therapy with ampicillin + Gentamycin +
Metronidazole) to prevent the spread of infection. Please do not eat anything at the moment. Once you are seen
by the specialist, they will decide upon further testing and treatment. Most likely, you will undergo a procedure
called ERCP (endoscopic retrograde cholangiopancreatography). This procedure is diagnostic as well as
therapeutic where we will introduce a small tube with a camera in the small bowel and try to visualize the bile duct.
The specialist might decide to take some pictures of the biliary system after the injection of contrast material. This
will help us to define the best possible treatment. Majority of these stones can be removed during ERCP. However,
some might eventually need surgery to remove them. Surgery would most likely be by laparoscopic.
- Later on, might undergo elective cholecystectomy to prevent chance of recurrence.