A 37-year-old woman is brought to the hospital with abdominal pain and confusion that began 24 hours ago. The patient describes the pain as stabbing and unremitting. It is worse in the upper abdomen and associated with nausea and frequent nonbloody emesis. Medical history is significant for type 1 diabetes mellitus and major depression. The patient has been hospitalized for diabetic ketoacidosis in the setting of insulin noncompliance as well as for a suicide attempt as a teenager. Temperature is 38.9 C (102 F), blood pressure is 90/60 mm Hg, pulse is 110/min, and respirations are 24/min. The patient is oriented to person but not to place or time. The mucous membranes are dry, and capillary refill is delayed. Heart and lung sounds are unremarkable. The abdomen is markedly tender in the right upper quadrant and epigastrium but with no rebound or guarding. Laboratory results are as follows: Which of the following is the most likely diagnosis?

Question

A 37-year-old woman is brought to the hospital with abdominal pain and confusion that began 24 hours ago.  The patient describes the pain as stabbing and unremitting.  It is worse in the upper abdomen and associated with nausea and frequent nonbloody emesis.  Medical history is significant for type 1 diabetes mellitus and major depression.  The patient has been hospitalized for diabetic ketoacidosis in the setting of insulin noncompliance as well as for a suicide attempt as a teenager.  Temperature is 38.9 C (102 F), blood pressure is 90/60 mm Hg, pulse is 110/min, and respirations are 24/min.  The patient is oriented to person but not to place or time.  The mucous membranes are dry, and capillary refill is delayed.  Heart and lung sounds are unremarkable.  The abdomen is markedly tender in the right upper quadrant and epigastrium but with no rebound or guarding.  Laboratory results are as follows:  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d83a_c673_bc81_03738e354c22_MD0003_00 This patient's presentation is consistent with acute cholangitis. The classic Charcot triad of fever, right upper quadrant (RUQ) pain, and jaundice (not noted in this patient, although it may develop with worsening hyperbilirubinemia) is only seen in 50%-75% of patients; Reynolds pentad (additional hypotension and altered mental status) is classically associated with severe disease. Acute cholangitis is a life-threatening infection that typically develops in the setting of biliary obstruction, which enables bacteria to enter the ampulla and biliary tree. Common etiologies include choledocholithiasis, malignancy, primary sclerosing cholangitis, and biliary interventions that result in incomplete bile drainage. In addition to leukocytosis with a left shift, classic laboratory findings include direct hyperbilirubinemia and elevated alkaline phosphatase (reflecting cholestasis). An anion gap metabolic acidosis (AGMA) commonly occurs from lactic acidosis with severe sepsis. The imaging modality of choice is a RUQ abdominal ultrasound, which demonstrates common bile duct dilation or evidence of biliary obstruction (eg, choledocholithiasis). Management includes broad-spectrum antibiotics, aggressive intravenous fluid resuscitation, and relief of the biliary obstruction with either endoscopic retrograde cholangiopancreatography or percutaneous drainage. (Choices A and C) Acetaminophen overdose and viral hepatitis also cause nausea/vomiting, RUQ pain, hyperbilirubinemia, and occasionally an AGMA; however, transaminases elevations are expected to be in the thousands. (Choice D) Diabetic ketoacidosis (DKA) also presents with abdominal pain, hyperglycemia, AGMA, and glucosuria. Although this patient is at high risk of DKA, the urinary ketones are normal, making DKA unlikely. In addition, hyperbilirubinemia is unexpected, and the abdominal pain due to DKA (which is possibly due to ileus or electrolyte abnormalities) is not classically localized to the RUQ. This patient's hyperglycemia without DKA is likely due to infection. (Choice E) Alcohol toxicity can cause alcoholic hepatitis, which also causes fever, RUQ pain, and jaundice. However, it typically causes a transaminase elevation with an aspartate aminotransferase to alanine aminotransferase ratio of ≥2. (Choice F) Acute mesenteric artery occlusion would cause severe abdominal pain and lactic acidosis, but a direct hyperbilirubinemia is unexpected, and this patient lacks typical risk factors (eg, peripheral artery disease, arrhythmias). (Choice G) Necrotizing pancreatitis presents with severe abdominal pain radiating to the back along with nausea and vomiting. Gallstone pancreatitis can sometimes occur with concurrent cholangitis; however, the lipase would be expected to be elevated. Educational objective: Acute cholangitis leads to right upper quadrant pain, fever, and jaundice (eg, direct hyperbilirubinemia); hypotension and altered mental status can occur with severe disease. An anion gap metabolic acidosis may be present due to lactic acidosis in severe sepsis. Common bile duct dilation is typically visible on right upper quadrant abdominal ultrasound.

A 37-Year-Old Woman Is Brought to the Hospital with Abdominal