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, obstructive airways 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:
Respiratory rate 30 breaths/min
SpO2 92% on 15 L/min O2 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.
a) 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
b) 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
c) 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 patients is not coagulopathic) is the gold standard and the best method of decompression and drainage.
Many candidates gave further fluid boluses despite the history of marginal oxygenation and previous administration of 4l crystalloid, without any assessment of likelihood of the patient being fluid responsive.
This question is identical to Question 9 from the second paper of 2016 in every way, with the exception of the examiner's comments at the end of the answer (which are less snarky this time). In 2016, the pass rate was still quite good (65%). The discussion section to Question 9 from 2016 is reproduced below with zero modification.
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).
Confirmation / investigation of cholangitis
Laurila, Jouko, et al. "Acute acalculous cholecystitis in critically ill patients."Acta anaesthesiologica scandinavica 48.8 (2004): 986-991.
Wang, Ay-Jiun, et al. "Clinical predictors of severe gallbladder complications in acute acalculous cholecystitis." Heart 1500 (2003): 8.
Boland, Giles W., et al. "Percutaneous cholecystostomy in critically ill patients: early response and final outcome in 82 patients." American Journal of Roentgenology 163.2 (1994): 339-342.