GROUP 5

General data

■N.A
■48/F
■Unemployed
■Roman Catholic
■Sampaloc, Manila
History of Present Illness

Patient was a known case of cholelithiasis by

ultrasound since 2017, but was lost to follow-
up. 2 months prior to consult, patient noted
epigastric pain, graded 6-8/10, with radiation
to the back, with assosicated nausea and
anorexia. No fever, vomiting, jaundice, no tea
colored urine, no acholic stools.
History of Present Illness

Consult at Manila Doctors Hospital,

ultrasound showed: Gall bladder distended
with thickened walls with 1.1 cm high
intesnity echo within the cystic duct. No
pericholic cystic fluid seen. Intrahepaitc
ducts and Common bile duct was not
dilated. Pancreas was obscured.
History of Present Illness

Patient was advised operation however

due to financial constraint, refused. Patient
was given unrecalled pain medications and
sent home.
In the interim, still with intermittent
epigastric pain aggravated by intake of food.
History of Present Illness

Three days prior to consult, noted

recurrence of epigastric pain, 8-9/10,
with radiation to the back, now with
jaundice, associated with fever
undocumented, and anorexia.
Persistence prompted consult.
Past Medical History

(+) Hypertension – 5 years, non

compliant with medications
(+) Hyperthyroidism
(-) Diabetes Mellitus
(-) PTB
(-) PTB treatment
(-) OR/hospitalizations
Family History

(+) Diabetes mellitus – maternal side

(+) Hypertension – maternal and
paternal side
(+) Cholecystectomy
Personal and Social History

■Occasional alcohol beverage drinker,

■Smoker, ~5 pack years
■Denies illicit drug use
Review of Systems

(-) weight loss

(+) occasional productive cough
(-) vomiting
(-) weakness
(-) difficulty of breathing
Physical Examination

awake, coherent, not in distress, jaundiced with vital signs of the following:
BP 90/60, HR 102, RR 20, T 39.0 99% o2 saturation.
Pink palpebral conjunctiva, icteric sclera, no cervical lymph adenopathies
Symmetric chest expansion, clear breath sounds,
Abdominal examination showed no scars, no lesions. Normoactive bowel
sounds, with noted direct tenderness on epigastric area and right upper
quadrant area. No rebound tenderness. No masses palpated.
DRE: no hemorrhoids, no lesions, no masses. Tight sphincteric tone, smooth
rectal vault, no palpable masses. Prostate palpated, smooth, non nodular,
approximately 3 finger breadths
Laboratories
CBC   PT 17.2 Crea 120 CXR Suspicious
densities, right
upper lobe
Hgb 10.2 INR 1.6 Na 136 ECG: Atrial
fibrillaiton in
RVR
Hct 30.1 % 47% K 4.17    
Act
WBC 30.9 PTT 48.0 Amyla 123    
5 se
Plt 178     Lipase 68    
               
  pH PO2 PCO2 HCO3 O2 BE  
sat
Laboratories

HBT Ultrasound:
Gall bladder non thickened, with intraluminal
0.6 cm hyperdensity with acoustic shadowing.
Intrahepatic ducts are dilated. CBD dilated at
1 cm, obscured distal CBD. No pericholic cystic
fluid seen. Obscured pancreas
Course in the ward
Patient was hydrated with PLR, Piperacillin
tazobactam was started. During her stay at
the ER, with note of hypotensive episodes,
70/40, parially responded to fluid
resuscitation. Norepinephrine was started
at low dose of 0.2 mkd, noted improvement
to 100/60, HR 110, RR 24. ABG was extracted
with noted of uncompensated metablic
acidosis with mild hypoxemia., Baseline CBG
was 178.
Course in the ward
HBT ultrasound was done with the above
findings. Patient was prepared for and
directed to the OR for percutaneous
transhepatic biliary drainage (PTBD).
She was transfused with 2 units FFP preop,
and 2 units intraop. Patient tolerated the
procedure (PTBD), with initial output of 80 cc
dark colored bile. Patient was then admitted
to SICU for close monitoring and intensive
care was done
Course in the ward
Patient was worked up for blirubins,
alkaline phosphatase, hepatitis profile,
thyroid functon tests, and whole abdominal
CT scan.
WAB CT Scan showed: tube drainage in
place. Markedly distended gallbladder, with
noted hyperdense focu. Dilated CBD and IHD,
with noted distal choledocholithiasis.
Consider GB hydrops. Pancreas was
unremarkable.
Course in the ward
Patient was stabilized and eventually
weaned off inotropes. She was scheduled for
definitive Open Cholecystectomy,
Intraoperative cholangiogram, Common Bile
Duct Exploration, Choledochotomy,
Choledocholithotomy, Tube
Choledochostomy, Completion
Cholangiogram with note of filling defect at
distal CBD on intraoperative
cholangiography, with 6x4cm thick walled
gallbladder with multiple stones, dilated
Course in the ward
Patient had unremarkable post op course,
and was discharged 4 days post op
Working Impression:

Cholangitis, severe
secondary to
Choledocholithiasis
DIFFERENTIAL
DIAGNOSIS
 SCHISTOSOMIASIS
RULE IN RULE OUT
(+) Abdominal pain Signs & Symptoms:
(+) Fever • Urticaria
(+) Anorexia • Weight loss

(+) Jaundice • Tender hepatomegaly

(+) Anemia Diagnostics:

• Labs: Eosinophilia
• Definitive Diagnosis: direct
visualization of schistosome eggs
in the stool or urine microscopy
• HBT Ultrasound:
• Hyperechoic thickened walls of
 VIRAL HEPATITIS
RULE IN RULE OUT
S/Sx Cannot totally rule out
(+) Epigastric pain Consider Hepa profile work up
(+) Undocumented fever
(+) Jaundice
Physical findings:
(+) Icteric sclera
(+) Direct tenderness, RUQ and
epigastric pain
Laboratory test findings:
(+) Prolonged Prothrombin time
 LIVER ABSCESS
RULE IN RULE OUT
Symptoms: ■ Hepatomegaly
■ RUQ abdominal pain
■ Fever
■ Positive amebic or
■ Jaundice echinococcal serology
■ Icteric sclera ■ Ultrasound: cystic mass in the
Physical Exam liver (multiple complex
■ Direct tenderness on RUQ and epigastric septations or homogenous
area
fluid)
Lab Dx:
■ Leukocytosis ■ CT scan: Complex hypodense
■ hyperbilirubinemia elevated serum alkaline mass with peripheral
phosphatase enhancement
■ mildly elevated AST
■ Ultrasound: Bile duct dilatation
 CHOLANGITIS
CASE RULE IN
■ 48/F
■ Unemployed ■ Known case of
Cholelithiasis(2017)
■ Sampaloc, Manila
■ Abdominal pain
■ Epigastric & RUQ pain
(Epigastric/RUQ)
■ Nausea & Vomiting
■ Fever
■ Jaundice
■ Jaundice
■ Fever
Diagnostic :
■ Anorexia
■ Hgb: 10.2, Hct: 30.1, WBC: 30.95
• Labs: Evidence of
inflammatory response
■ Amylase: 123, Lipase: 68 (leukocytosis, high CRP),
■ HBT Ultrasound: Gall bladder non Abnormal liver function tests
thickened, with intraluminal 0.6 cm • Imaging: Biliary dilatation or
hyperdensity with acoustic
evidence of an etiology
shadowing. Intrahepatic ducts are
dilated (stricture, stone, stent, etc.)
FINAL DIAGNOSIS
 Cholangitis, Severe
Secondary to Choledocolithiasis
Presumptive TB
Hypertension
DISCUSSION
 CHOLANGITIS
■is an ascending bacterial infection in
association with partial or complete
obstruction of the bile ducts
■is one of the two main complications of
choledochal stones

*Biliary bacterial contamination alone does

not lead to clinical cholangitis; the
combination of both significant bacterial
contamination and biliary obstruction is
CAUSES
■Gallstones are the most common cause of
obstruction
■other causes are benign and malignant
strictures, parasites, instrumentation of the
ducts and indwelling stents, and partially
obstructed biliary-enteric anastomosis
CAUSATIVE AGENTS
■Escherichia coli
■Klebsiella pneumoniae
■Streptococcus faecalis
■Enterobacter
■Bacteroides fragilis
SIGNS/SYMPTOMS
■ present as anything from a mild, intermittent, and
self-limited disease to a fulminant, potentially life-
threatening septicemia
■ Fever
Charcot’s triad
■ Epigastric/RUQ pain
Reynolds’ pentad
■ Jaundice
■ Septic shock
■ Altered mental status
DIAGNOSTICS
Clinical • History of biliary disease
Context • Fever or chills
• Jaundice
• Abdominal pain (RUQ or upper abdomen)
Laboratory • Evidence of inflammatory response:
Data leukocytosis, high CRP
• Abnormal liver function tests: increased
serum alkaline phosphatase, aspartate
aminotransferase, alanine
aminotransferase, γ – glutamyl
transpeptidase
Imaging • Biliary dialation or evidence of an etiology
Findings (stricture, stone, stent, etc.)
Source: TG13 Updated Tokyo Guidelines, 201
DIAGNOSTICS

■Suspected Diagnosis: two or more items

in ‘Clinical Context’
■Definitive Diagnosis: Charcot’s triad +
two or more items in ‘Clinical Context’ +
both items in ‘Laboratory Data’ + item in
‘Imaging Findings’

Source: TG13 Updated Tokyo Guidelines, 201

GRADING
GRADE CRITERIA
III Associated dysfunction in at least one of the
SEVERE following organ systems:
• Cardiovascular: hypotension requiring
dopamine > 5 μg/kg/min or any dose of
norepinephrine
• Nervous: decreased level of consciousness
• Respiratory: PaO2/FiO2 ratio of < 300
• Renal: serum creatinine > 2.0 mg/dL
• Liver: PT-INR > 1.5
• Hematologic: platelet count < 100,000/mm3
II Does not respond to the initial medical treatment
MODER but is not associated with organ dysfunction
ATE Risk of increased severity without early biliary
Source: TG13 Updated Tokyo Guidelines, 201
GRADING
GRADE CRITERIA
II Associated with any two of the following:
MODERA • Abnormal WBC count (> 12,000/mm3 or <
TE 4.000/mm3)
• High fever (> 39°C)
• Age > 75 years
• Hyperbilirubinemia
• Hypoalbunemia
I Responds to initial medical treatment
MILD Does not meet the criteria for Grade I or II

Source: TG13 Updated Tokyo Guidelines, 20

MANAGEMENT
GRADE CRITERIA
I Initial medical therapy with antibiotics
MILD For non-responders: biliary drainage should be considered
Intervention for etiology (eg. choledocholithiasis, pancreato-
biliary malignancy) endoscopic, percutaneous, or operative
intervention after work-up
II Early endoscopic or percutaneous drainage
MODERATE Emergency operative drainage with a T-tube
Definitive procedure to remove cause of cholangitis
III Appropriate organ support
SEVERE Urgent biliary drainage
• ERCP + papillotomy
• PTC with catheter drainage
• Laparotomy with decompression of the bile duct with a T-
tube
Definitive procedur e to remove cause of cholangitis
Source: TG13 Updated Tokyo Guidelines, 20
PROGNOSIS
■Overall mortality rate of approximately 5%.
Increases if it is associated with renal
failure, cardiac impairment, hepatic abscess
and malignancies.