Review Question - QID 103033

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Ascending Cholangitis Treatment First-line QID: 103033 (M3.GI.12.10)

QID 103033 (Type "103033" in App Search)

A 40-year-old female visits the emergency department with right upper quadrant pain and fever of 2-hours duration. She denies alcohol, cigarette, and drug use and reports no other medical problems. Body mass index is 30 kg/m^2. Her temperature is 38.5 degrees Celsius (101.3 degrees Fahrenheit), blood pressure is 130/80 mm Hg, pulse is 90/min, and respirations are 18/min. Jaundice is present in the sclera and at the base of the tongue. The abdomen is tender in the right upper quadrant. Liver function test (LFTs) reveal elevated direct and total bilirubin and alkaline phosphatase of 500 U/L. IV Ampicillin-gentamicin is administered, fluid resuscitation is initiated, and over 24 hours the patient’s fever improves. Which of the following is the next step in the management of this patient:

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Elective laparoscopic cholecystectomy

40%

2/5

Urgent open cholecystectomy

0/5

Endoscopic retrograde cholangiopancreatography (ERCP)

60%

3/5

Administer bile acids

0/5

Extracorporeal shock wave lithotripsy

0/5

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The patient in this clinical vignette is presenting with symptoms for acute cholangitis. The next step in the management of this patient is to schedule endoscopic retrograde cholangiopancreatography (ERCP).

This patient is presenting with Charcot’s triad for acute cholangitis: fever, right upper quadrant pain, and jaundice. Her elevated bilirubin and alkaline phosphatase levels also suggest extrahepatic obstruction. Administration of antibiotics and fluid resuscitation will improve clinical symptoms in up to 80% of patients, at which point ERCP may be scheduled to remove the patient’s obstruction. ERCP has a lower morbidity rate than surgical drainage. If antibiotics and fluid resuscitation fail, emergent ERCP for biliary decompression is necessary.

Abraham et al. review gallstones stating that the incidence increases with age and most are asymptomatic. When symptoms present, the most common is biliary colic which is due to the gallstone(s) blocking the cystic duct. Pain presents in the epigastrium/right upper quadrant and will typically last between 1-5 hours before subsiding. Management of acute biliary colic consists of NSAIDs or narcotics.

Buyukasik et al. analyze the diagnostic, therapeutic, and complication rates of ERCP in patients who do not respond to medical treatment in the setting of acute purulent cholangitis. They found that the success rate to be 94% which is consistent with other studies and a complication rate of 1.38% with a mortality rate of .21%. The patients experienced significant relief of symptoms following the ERCP.

Incorrect answers:
Answers 1,2: Cholecystectomy is indicated for acute or chronic cholecystitis rather than acute cholangitis. Eliminating the risk of systemic infection in this patient and relieving biliary obstruction are more immediate priorities than gallbladder removal. Cholecystectomy may be scheduled at a later date to prevent recurrence
Answers 4,5: Bile acids and extracorporeal shock wave lithotripsy are therapies for gallstones and are not indicated in this patient