A 45-year-old woman is brought to the emergency department with severe abdominal pain, fever, and confusion. The patient's husband reports that, yesterday, she began to have worsening right-sided abdominal pain associated with nausea and several episodes of vomiting. This morning, she has been slow to respond and is confused about where she is. The patient has a history of depression and takes sertraline. Temperature is 39.5 C (103.1 F), blood pressure is 88/50 mm Hg, pulse is 104/min, and respirations are 26/min. She appears ill and confused, and the sclera are icteric. Abdominal examination demonstrates significant tenderness with guarding in the right upper quadrant. Which of the following is the most likely underlying cause of this patient's current condition?

Question

A 45-year-old woman is brought to the emergency department with severe abdominal pain, fever, and confusion.  The patient's husband reports that, yesterday, she began to have worsening right-sided abdominal pain associated with nausea and several episodes of vomiting.  This morning, she has been slow to respond and is confused about where she is.  The patient has a history of depression and takes sertraline.  Temperature is 39.5 C (103.1 F), blood pressure is 88/50 mm Hg, pulse is 104/min, and respirations are 26/min.  She appears ill and confused, and the sclera are icteric.  Abdominal examination demonstrates significant tenderness with guarding in the right upper quadrant.  Which of the following is the most likely underlying cause of this patient's current condition?

Quizplus · Accepted Answer

11ec160b_3932_9489_9249_1fe69220a6c2_MD0001_00 This patient with fever, right upper quadrant (RUQ) pain, jaundice, confusion, and hypotension has acute cholangitis (AC). AC is a life-threatening infection that typically develops in the setting of biliary obstruction, which enables bacteria to proliferate within the biliary tree. Obstruction can occur in a variety of settings (eg, malignant biliary obstruction, biliary stricture) but is most commonly caused by a calculous obstruction of the common bile duct (ie, choledocholithiasis). AC is characterized by fever, RUQ pain, and jaundice (Charcot triad); hypotension and altered mental status (Reynold pentad) occur in severe cases. Laboratory findings include leukocytosis, direct hyperbilirubinemia, and elevated alkaline phosphatase. Abdominal imaging (eg, ultrasound) demonstrates common bile duct dilation, possibly with evidence of an obstructing stone. Management includes antibiotics, intravenous fluid resuscitation, and endoscopic or percutaneous techniques to relieve the biliary obstruction. (Choice A) Acute pancreatitis is characterized by acinar cell dysfunction and necrosis. Although patients can develop fever and hypotension, typical manifestations include epigastric pain radiating into the back, nausea/vomiting, and elevated lipase. Jaundice is unexpected unless a gallstone obstructs both the common bile and the pancreatic ducts, resulting in simultaneous AC. (Choice C) Hepatic sarcoidosis, which causes extensive noncaseating granuloma formation in the liver, can present with cholestasis (eg, elevated alkaline phosphatase, jaundice, pruritus) and hepatomegaly. However, sepsis, hypotension, and confusion are unexpected, and most patients have evidence of systemic sarcoidosis (eg, hilar adenopathy, cough). (Choice D) Autoimmune hepatitis causes immune-mediated hepatocyte destruction and usually presents with asymptomatic transaminitis or the insidious onset of fatigue and anorexia. Fever, tachycardia, and hypotension are unexpected and more consistent with infection due to AC. (Choice E) Acetaminophen overdose can cause RUQ pain, jaundice, vomiting, and confusion, typically around 72 hours after ingestion. However, fever is atypical and more consistent with AC. (Choice F) Although a mass in the pancreatic head can cause biliary obstruction, pancreatic tail masses are not located near the biliary tree and therefore are not usually associated with AC. They more commonly present with epigastric abdominal pain and weight loss. Educational objective: Acute cholangitis is a life-threatening infection characterized by fever, right upper quadrant pain, and jaundice (Charcot triad); hypotension and altered mental status (Reynold pentad) occur in severe cases. Acute cholangitis typically develops in the setting of biliary obstruction; common etiologies include gallstones, malignancy, and strictures.

A 45-Year-Old Woman Is Brought to the Emergency Department with Severe