A 63-year-old man comes to the emergency department due to worsening pain in the right upper quadrant, nausea, and vomiting since last night. He woke up at midnight with abdominal discomfort and nausea. He could not fall back to sleep due to the increasing pain as well as malaise and shaking chills. The patient had 2 episodes of vomiting this morning. He has gastroesophageal reflux disease and takes esomeprazole occasionally. He also has a history of hypertension and osteoarthritis. The patient drinks a glass of wine daily with dinner but does not use tobacco or illicit drugs. On initial evaluation, he appears uncomfortable due to pain. Temperature is 38.3 C (101 F), blood pressure is 96/65 mm Hg, pulse is 102/min and regular, and respirations are 18/min. Physical examination shows mild scleral icterus. Mucous membranes are dry. The abdomen is soft and nondistended, with moderate tenderness in the right upper quadrant. There is no rebound tenderness. Bowel sounds are active. Laboratory results are as follows: Serum creatinine is 0.9 mg/dL. Abdominal ultrasonography reveals increased liver echotexture consistent with fatty infiltration, several small gallstones, and dilated biliary ducts. Intravenous fluids and empiric antibiotics are administered, and the blood pressure and tachycardia improve. Which of the following is the best management strategy for this patient?

Question

A 63-year-old man comes to the emergency department due to worsening pain in the right upper quadrant, nausea, and vomiting since last night.  He woke up at midnight with abdominal discomfort and nausea.  He could not fall back to sleep due to the increasing pain as well as malaise and shaking chills.  The patient had 2 episodes of vomiting this morning.  He has gastroesophageal reflux disease and takes esomeprazole occasionally.  He also has a history of hypertension and osteoarthritis.  The patient drinks a glass of wine daily with dinner but does not use tobacco or illicit drugs.  On initial evaluation, he appears uncomfortable due to pain.  Temperature is 38.3 C (101 F), blood pressure is 96/65 mm Hg, pulse is 102/min and regular, and respirations are 18/min.  Physical examination shows mild scleral icterus.  Mucous membranes are dry.  The abdomen is soft and nondistended, with moderate tenderness in the right upper quadrant.  There is no rebound tenderness.  Bowel sounds are active.  Laboratory results are as follows:  Serum creatinine is 0.9 mg/dL.  Abdominal ultrasonography reveals increased liver echotexture consistent with fatty infiltration, several small gallstones, and dilated biliary ducts.  Intravenous fluids and empiric antibiotics are administered, and the blood pressure and tachycardia improve.  Which of the following is the best management strategy for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf25_0ea9_8f63_31e0e43ee260_MD0005_00 This patient's presentation is consistent with sepsis due to acute cholangitis. The biliary tract is typically sterile; however, biliary obstruction (eg, gallstone, bile duct stenosis, cholangiocarcinoma) or incompetence of the sphincter of Oddi (eg, due to previous sphincterotomy) can disrupt normal bile flow mechanisms and allow bacteria from the duodenum to ascend the biliary tract, causing infection. Less commonly, hematogenous spread of bacteria to the biliary tract may occur. Patients classically have the Charcot triad of pain in the right upper quadrant, fever, and jaundice (up to 75% of cases), and some patients can be severely ill with the additional findings of hypotension and altered mental status (Reynolds pentad). Laboratory findings typically show leukocytosis as well as a cholestatic pattern of liver function tests with marked elevation in bilirubin and alkaline phosphatase and milder elevation in aminotransferases. Ultrasound of the right upper quadrant demonstrating biliary duct dilation can be helpful in the initial diagnosis. Aggressive intravenous volume resuscitation should be administered, and blood cultures should be collected, followed immediately by empiric antibiotic therapy offering broad coverage of enteric organisms (eg, piperacillin/tazobactam, ciprofloxacin with metronidazole). Definitive treatment requires biliary drainage (eg, gallstone removal, stent placement), which is best accomplished by endoscopic retrograde cholangiopancreatography (ERCP) within 24-48 hours or more urgently in severe cases. (Choice A) Antibiotics alone are insufficient treatment for acute cholangitis as the infection rarely resolves without biliary decompression. (Choices B and D) Eventual cholecystectomy is likely indicated in this patient with acute cholangitis probably due to gallstone disease. However, cholecystectomy is not a priority at this time and does not address the acute infection in the biliary tract. (Choice E) Open surgical biliary drainage (often with accompanying cholecystectomy) is sometimes required in patients with acute cholangitis in whom ERCP fails to relieve biliary obstruction. However, ERCP is associated with a lower morbidity rate compared with open surgical biliary drainage and is the preferred intervention. Educational objective: Acute cholangitis is typically due to ascension of enteric bacteria into the biliary tract in the setting of impaired biliary drainage (eg, gallstone obstruction). It classically presents with pain in the right upper quadrant, fever, and jaundice (Charcot triad). Definitive treatment requires biliary decompression, which is best accomplished by endoscopic retrograde cholangiopancreatography. References: Factors predicting adverse short-term outcomes in patients with acute cholangitis undergoing ERCP: a single center experience. (http://www.ncbi.nlm.nih.gov/pubmed/24634711)

A 63-Year-Old Man Comes to the Emergency Department Due to Worsening