Let's move to our next case.
A 67-year-old woman is admitted to the hospital with 2
days of epigastric abdominal pain, fever and jaundice.
2 days ago, she had sudden onset abdominal pain
then noticed her eyes and skin beginning to turn yellow.
Her vitals are notable
for temperature of 39.3 C,
blood pressure 105/58 (mmHg)
and heart rate 105 (bpm).
Abdominal exam reveals right upper
quadrant tenderness but no guarding.
Her labs are notable for a white cell count of 15,000/uL,
ALT 550 (U/L) and total bilirubin of 7.2 (mg/dL)
A right upper quadrant ultrasound shows
dilated intrahepatic and extrahepatic bile ducts,
gallstones, a normal gallbladder
wall and no pericholecystic fluid.
So we are asked what is the
So let's point out that she has:
epigastric pain, fever and jaundice -
which is something called Charcot's triad
She has fever, tachycardia and leukocytosis
with a suspected biliary source
given her elevated bilirubin
and she meets criteria for sepsis.
And on imaging, she has
dilated bile ducts with gallstones
but none of those concerning
findings for acute cholecystitis.
So let's talk again
Recall that this means the gallstone is
now impacted in the common bile duct.
Patients will present very
similarly to cholelithiasis.
They will often have a transient elevation
in their serum AST, ALT, and bilirubin.
So, there are several
complications that can occur.
Due to blockage of the common bile duct, you can
develop an ascending infection, called cholangitis
Or you may also develop
The diagnosis is made by something called
MRCP which is short for magnetic retrograde cholangiopancreatography.
An example is shown here.
You may also do right upper quadrant
ultrasound which can detect ductal dilatation.
And treatment is with a
procedure called an ERCP,
this is endoscopic retrograde
This is a procedure by which we can remove the
stone that's impacted in the common bile duct.
So, we mentioned the
complication of gallstone pancreatitis.
This occurs when the gallstone is
impacted in the common bile duct
such that it also blocks
the pancreatic duct.
When this happens, patients
may develop pancreatitis.
We also mentioned the
procedure called an ERCP.
Basically, what this looks like is a
scope that is advanced into the duodenum
and then we use a guide wire to insert through
the sphincter of Odi into the common bile duct.
This guide wire could help
us either do a sphincterotomy
which means widening the
sphincter to allow passage of the stone,
or we can also remove the stone
directly form the common bile duct.
So, patients may present
with certain symptoms,
that one of which we
characterize as Charcot's triad.
This is a triad of symptoms of fever,
right upper quadrant pain, and jaundice.
When the infection becomes more severe, they may
develop what's called, Reynold's pentad.
This is when they have fever, right
upper quadrant pain and jaundice,
but also the addition of hypotension
and altered mental status.
These are just two common eponyms that
you should learn for test-taking purposes.
So now let's get to the
management of this condition,
If your diagnosis is unclear, you may do an MRCP or
an endoscopic ultrasound to confirm the diagnosis
if you don't already have that based
on their ultrasound or CT imaging.
You may give supportive care with IV fluids
And broad-spectrum IV antibiotics, again wanting to
target the GI flora so gram negatives and anaerobes
And lastly, you may then do an ERCP to
remove the stone and perform a sphincterotomy.
Here on the right, you can see
an example of an ERCP image.
That arrow indicates a small darkened
area within the common bile duct.
That is a gallstone impacted.
So now, let's return to our case.
A 67-year-old woman with epigastric
abdominal pain, fever and jaundice
which is Charcot's triad for cholangitis.
She has signs of sepsis
with a suspected biliary source
and on imaging, she has dilated bile
ducts but no signs of acute cholecystitis.
So, we now know that the presence of the dilated
bile ducts with Charcot's triad of symptoms,
in the case that she likely has a stone impacted in
the common bile duct leading to ascending cholangitis.
So the recommended management
would be supportive care with IV antibiotics
and then ERCP to disimpact
the common bile duct.