You are asked to review a confused 65-year-old female in the Emergency Department, who has presented with abdominal pain and vomiting. She has a history of ischaemic heart disease and atrial fibrillation.
On examination she is jaundiced, mildly confused and has right upper quadrant tenderness. Her vital signs, after 4 litres intravenous 0.9% saline, are as follows:
- Temperature 39.5°C
- Respiratory rate 30 breaths/min
- SpO2 92% on 15 L/min oxygen via a reservoir mask
- Heart rate 120 beats/min (atrial fibrillation)
- Blood pressure 88/48 mmHg
An abdominal ultrasound scan shows a dilated common bile duct and enlarged gall bladder with mural oedema.
Outline your management of this patient
The patient is most likely to have acute ascending cholangitis, which needs rapid resuscitation and definitive treatment.
- Admit to the intensive care unit
- Provide resuscitative and organ supportive care.
- Resuscitate, investigate and treat simultaneously.
- Actively consider the need intubation and ventilation given her respiratory failure, confusion and haemodynamic instability,
- Central venous and arterial lines need to be inserted and monitoring commenced.
Blood taken for investigations:
FBC, Coags, UECs, LFTs, ABGs, cultures
- No further intravenous fluid bolus
- Commence vasopressor support, aiming for a MAP > 65mmHg.
- Ensure referral to gastroenterology team for further investigation and management
- Consider MRCP or abdominal CT scan if diagnosis uncertain
- Commence broad-spectrum empiric antibiotic therapy.
Need good gram negative, gram positive and include anaerobic cover if very unwell:
Examples include: amoxycillin and gentamicin and metronidazole piperacillin/tazobactam
- Source control with decompression & drainage of her biliary tract.
- By most recent international guidelines this is Grade III (severe) acute cholangitis and thus the biliary tree must be urgently decompressed and drained.
- This can be done either endoscopically (ERCP) or percutaneously.
- Open surgery is not indicated in this situation.
- ERCP +/- sphincterotomy (provided the patient is not coagulopathic) is the gold standard and the best method of decompression and drainage.
- Additional Examiners‟ Comments:
- Candidates‟ description of the management of the case was superficial with lack of perspective or explanation of rationale, e.g. “I would assess the airway…may need to regularly assess” with no indication as to why, causes for concern, what they would look for etc. There was poor discussion and/or explanation of airway management, source control techniques, fluid assessment, antibiotic choice, differential diagnosis of hypoxia, impact of co-mobidities. There was over-emphasis on the utility of echo before addressing the basics of oxygenation.
This patient has to have some sort of biliary sepsis, because she manifests not only Charcot's Triad (abdominal pain, jaundice and fever), but the full Reynolds pentad (same, but with confusion and hypotension).
- A: intubate the confused uncooperative patient
- B: ventilate with mandatory mode
- C: insert CVC, arterial line;
- assess the need for further fluid resuscitation
- commence vasopressors if it appears that the patient is well filled
- D: commence sedation and analgesia
- E: correct electrolyte derangements and acidosis
- F: Assess renal function; insert IDC
- G: NGT for gastric decompression
- H: keep Hb >70
- I: broad spectrum antibiotics
Confirmation / investigation of cholangitis
- Repeat LFTs
- Inflammatory markers
- CT of the abdomen ( the patient still has not me TG13 criteria, insofar as she has no evidence of any bile duct stone or mass). Possible causes of duct obstruction could include stones (commonest), tumour, abscess, vascular malformation or parasites. Each might call for a different approach.
- MRCP (can detect non-calcified stones more easily than CT, and is more sensitive for making the diagnosis of malignant obstruction)
- Antibiotics: Sanford Guide recommends Tazocin or Meropenem.
Of the patients with cholangitis, 70-80% will respond to conservative management (i.e. they get better with antibiotics and are clinically well by the time they get to have an ERCP).
- ERCP: the treatment of choice whenever feasible (stent or sphincterotomy)
- Percutaneous transhepatic cholangiography (PTCC): the bile duct can be decompressed by inserting a needle into the liver and draining the pus that way. PTC can also be used to put stents in, image the duct, extract stones, etc.
- Percutaneous cholecystostomy: if the gall bladder is accessible, the simplest thing would be to put a drain into it (just as in the case of acalculous cholecystitis)
- Surgical decompression by T-tube: if ERCP is impossible, inserton of a T-tube has a lower complication rate than open cholecystectomy and exploration.
- Surgical cholecystectomy and exploration of CBD: this is the approach which led to the mortality rates in excess of 50% during the 1960s and 70s.
- Cholecystectomy: ultimately, the gall bladder must be removed, but it should ideally happen when the inflammation has settled down. Acute cholecystitis makes this organ friable and difficult to handle laparoscopically, and the morbidity from open procedures is much greater. Thus, if you can afford to wait, you really should.
- Oncology referral: in the event that the CBD was compressed by a head of pancreas mass or somesuch
- Mechanical ventilation - mandatory mode while severely septic; then weaning off the ventilator
- Haemodynamic support with vasopressors
- Management of AF with amiodarone
- Vigilant monitoring for myocardial infarction with daily ECGs
- Nutrition - post-ERCP, one should be able to commence NG diet
- Adequate analgesia
- PPI, heparin, etc