Review Question - QID 103065

This patient presents with acute cholangitis complicated by septic shock. The most appropriate next step in management is decompression with a percutaneous cholecystostomy.

Acute cholangitis classically presents with fever, right upper quadrant pain, and jaundice, known as Charcot's Triad. However, patients may progress to septicemia. Obstruction may be due to a biliary stone, or other anatomic blockage such as a pancreatic mass, biliary stricture, or iatrogenic disruption. As with other approaches to sepsis, resuscitation and source control are paramount. Initial elucidation of the source of obstruction is best done with magnetic resonance cholangiopancreatography (MRCP) or abdominal CT with contrast. Patients who present and are unsuitable for surgery should be decompressed with either endoscopic or percutaneous drainage.

Ahmed et al. discuss the management of gallstone disease and their complications. They underscore the importance of prompt management of known cholelithiasis, as the risk of stone impaction or distal advancement of the stone into the biliary tree places the patient at risk for choledocholithiasis, ascending cholangitis, and gallstone pancreatitis.

Hanau et al. discuss the diagnosis and management of acute cholangitis. They note the utility of CT cholangiography and MRCP as important diagnostic adjuncts to delineate the level of obstruction. With regard to drainage, they comment that the endoscopic route is favored over percutaneous drainage, because of a lower risk of complication.

Figure A is a coronal slice of an MRCP image showing a markedly dilated hepatic duct, cystic duct, and gallbladder. Note the presence of a stone at the neck of the cystic duct. External compression of the common bile duct by a cystic duct stone is known as Mirizzi's Syndrome, and occurs in 0.5-2% of all cholecystectomies. Illustration A shows a schematic of a percutaneous cholecystostomy tube placement. The pigtailed drain is placed through the right lobe of the liver in order to stabilize the drain, and prevent accidental dislodgement.

Incorrect Answers:
Answer 1: Rifaximin and lactulose are medical therapies for hepatic encephalopathy.
Answer 2: Ursodeoxycholic acid is appropriate in patients with Primary Sclerosing Cholangitis.
Answer 3: This patient is too clinically unstable for the operating room. Decompression followed by interval cholecystectomy is the appropriate course of action.
Answer 5: This patient's acute cholangitis can be appropriately managed through more conservative means without exposing the patient to such an invasive procedure.