A 45-year-old woman comes to the emergency department with 1 day of fever, chills, nausea, and vomiting. She has had progressively worsening right upper quadrant abdominal pain for the past 2 days. The patient has a history of depression as a teenager and attempted suicide. She currently takes no medications and does not use alcohol or illicit drugs. Temperature is 39.5 C (103.1 F), blood pressure is 90/48 mm Hg, pulse is 98/min, and respirations are 30/min. BMI is 36 kg/m2. The patient appears ill and confused. Skin and sclera are icteric. Cardiopulmonary examination is normal. Marked tenderness and guarding are present at the right upper quadrant of the abdomen. She has no flank pain or dullness. Laboratory results are as follows:
| Liver studies | |
| Total bilirubin | 7.2 mg/dL |
| Direct bilirubin | 5.4 mg/dL |
| Alkaline phosphatase | 714 U/L |
| Aspartate aminotransferase (SGOT) | 75 U/L |
| Alanine aminotransferase (SGPT) | 60 U/L |
| Lipase | 81 U/L (normal: 10-140) |
| Complete blood count | |
| Hemoglobin | 14.1 g/dL |
| Platelets | 306,000/mm3 |
| Leukocytes | 19,200/mm3 |
| Neutrophils | 81% |
| Lymphocytes | 16% |
Further workup in this patient would most likely show which of the following?
Acute cholangitis | |
Etiology |
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Clinical |
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Diagnosis |
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Treatment |
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AMS = altered mental status; ERCP = endoscopic retrograde cholangiopancreatography; | |
This patient with fever, jaundice, and right upper quadrant abdominal pain (Charcot triad) most likely has acute cholangitis (AC). Confusion and hypotension (Reynolds pentad) are also sometimes seen in severe disease. AC occurs in the setting of biliary stasis, which is most commonly caused by gallstones, malignancy, or stenosis. Elevated intrabiliary pressure allows for disruption of the bile-blood barrier and translocation of bacteria from the hepatobiliary system into the bloodstream.
Diagnostic findings reflect biliary obstruction, with ultrasound or CT scan demonstrating dilation of the intrahepatic and common bile duct. In addition to leukocytosis with left shift, laboratory results characteristically demonstrate direct hyperbilirubinemia, elevated alkaline phosphatase, and elevated gamma-glutamyl transpeptidase. Aminotransferases are typically only mildly elevated.
Supportive care, broad-spectrum antibiotics, and biliary drainage, preferably by endoscopic retrograde cholangiopancreatography with sphincterotomy, are the mainstays of treatment. Other options for biliary decompression include percutaneous transhepatic cholangiography with drain placement and open surgical decompression.
(Choice B) Acute pancreatitis also presents with abdominal pain and results in pancreatic edema and inflammation visible on CT scan. Although gallstone pancreatitis may present with cholestatic liver function studies (due to obstruction of the ampulla), the normal lipase level makes this diagnosis much less likely.
(Choice C) Although a prior suicide attempt is the greatest risk factor for future attempts, acetaminophen overdose is typically characterized by markedly elevated transaminases (>3000 U/L). In addition, the hyperbilirubinemia is primarily indirect, and fever is atypical.
(Choice D) Primary sclerosing cholangitis is characterized by short, annular strictures alternating with a normal bile duct ("beads on a string") visible on ultrasound. Although it has a cholestatic pattern on liver function studies, patients are frequently asymptomatic or have chronic fatigue and pruritus on presentation. Acute hypotensive illness and leukocytosis are not typical.
(Choice E) Acute cholecystitis presents with thickening of the gallbladder wall and pericholecystic fluid visible on ultrasound. It can cause fever, leukocytosis, and right upper quadrant pain, but markedly elevated bilirubin and alkaline phosphatase are not typical.
Educational objective:
Fever, jaundice, and right upper quadrant abdominal pain (Charcot triad) are consistent with acute cholangitis. Ultrasound or CT scan most commonly shows common bile duct dilation. In addition to leukocytosis with left shift, laboratory studies reflect biliary stasis and demonstrate direct hyperbilirubinemia, elevated alkaline phosphatase, and mildly elevated aminotransferases.