A 52-year-old woman is brought to the emergency department due to a 2-day history of fever, chills, abdominal pain, nausea, and vomiting. Her husband says that she has become progressively confused and lethargic today. The patient has a history of dyspepsia and underwent laparoscopic cholecystectomy 2 years ago but still has occasional upper abdominal discomfort. Medical history also includes hyperlipidemia and diet-controlled diabetes mellitus. The patient recently started taking herbal supplements to help lose weight. She drinks alcohol at social events but does not use tobacco or illicit drugs. There is no history of recent travel, but the family had a barbecue lunch before her symptoms started. Other family members who consumed the same food are asymptomatic. Temperature is 39.4 C (103 F), blood pressure is 90/50 mm Hg, pulse is 126/min, and respirations are 20/min. BMI is 34 kg/m². The patient has scleral icterus and dry mucous membranes. The lungs are clear to auscultation and cardiac examination is normal with the exception of tachycardia. There is marked right upper quadrant and epigastric tenderness without rebound tenderness. The patient has no rash or enlarged lymph nodes. She is somnolent but wakes to touch; otherwise, her neurologic examination is unremarkable. Laboratory results are as follows: Abdominal ultrasonography reveals fatty infiltration of the liver, postcholecystectomy changes, and dilated biliary ducts and common bile duct. Which of the following is the most likely cause of this patient's current condition?

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Explanation: 11ec2b69_bf25_d1fb_8f63_cff856c764e3_MD0005_00 This patient most likely has sepsis due to acute cholangitis. The obstruction of bile flow allows for bacteria from the duodenum to ascend the biliary tract and cause infection; although gallstone disease is the most common cause, patients who have undergone cholecystectomy remain at risk due to other mechanisms (eg, biliary stricture, malignant biliary obstruction, postcholecystectomy migration of a biliary clip). Patients characteristically have the Charcot triad of fever, right upper quadrant (RUQ) pain, and jaundice; in severe cases, such as in this patient, they develop accompanying hypotension and altered mental status, constituting Reynolds pentad. Marked abdominal or RUQ tenderness with scleral icterus or jaundice is typically present on physical examination. Laboratory results typically demonstrate leukocytosis and cholestatic liver function abnormalities, with predominant elevations in serum bilirubin and alkaline phosphatase. The diagnosis is aided by RUQ ultrasound demonstrating biliary duct dilation. Magnetic resonance cholangiopancreatography (MRCP) is highly useful in identifying biliary strictures or other, less common causes of biliary obstruction (eg, biliary tumor). (Choice B) Acute viral hepatitis (eg, hepatitis A) typically presents with marked elevations in bilirubin and aminotransferases. A predominant elevation in alkaline phosphatase is not typical. (Choice C) Entamoeba histolytica causes a diarrheal illness accompanied by fever and sometimes development of an amebic liver abscess with associated RUQ pain. Infection typically occurs in developing countries through ingestion of contaminated food or water. This patient's ultrasound showed no abscess, and his lack of recent travel makes entamebal infection unlikely. (Choice D) Drug-induced liver injury has been documented to occur with numerous medications; over-the-counter herbal supplements may account for up to 20% of cases. Patients typically have elevated bilirubin, aminotransferases, and alkaline phosphatase; however, the presentation is usually subacute, unlike this patient's acute development of high fever and abdominal pain. (Choice E) Infection with Escherichia coli O157:H7 typically follows consumption of contaminated food (eg, undercooked ground beef, lettuce) and presents with abdominal pain, fever, and bloody diarrhea. Hemolytic uremic syndrome can develop and is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal insufficiency. Infection typically occurs in epidemics; lack of illness in this patient's family members makes the infection less likely. Educational objective: Acute cholangitis typically results from biliary obstruction and is characterized by fever, right upper quadrant pain, and jaundice. Severe acute illness with hypotension and altered mental status can occur. The diagnosis is usually made based on clinical presentation and imaging demonstrating biliary duct dilation. References: Techniques of biliary drainage for acute cholangitis: Tokyo Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/17252295) Biliary complications secondary to post-cholecystectomy clip migration: a review of 69 cases. (http://www.ncbi.nlm.nih.gov/pubmed/20049550)

A 52-Year-Old Woman Is Brought to the Emergency Department Due