This
60 years old lady presented with history of pain in right hypochondrium and
jaundice for 5 days in the gastroenterology department. In the background
history, patient was operated for gall stone disease 3 months back and surgery
done was open cholecystectomy with bile duct exploration. After that ERCP was
done twice to remove bile duct stones. After the surgery patient remained
asymptomatic until 5 days back when she developed pain in right hypochondrium
which was moderate in intensity, continuous, non colicky, sharp piercing type
of pain associated with yellowish discolouration of eyes. Jaundice was
associated with generalized itching, not hampering her activities or sleep,
clay coloured stools and high coloured urine. There was no h/o fever, abdominal
distension, hematemesis, melena, loose motions or constipation. There was no
h/o altered sensorium, decreased urine output, cough with expectoration. On
examination she was found to have shock, pallor, icterus. There was no
lymphadenopathy, cyanosis, edema and jvp was not raised. Her TLC was normal but
renal function were deranged. Total bilirubin (Bil-14.6, Direct-12.1) was
raised. So considering the possibility of cholangitis causing septic shock and
acute kidney injury due to hypotension or ATN, she was started on broad
spectrum antibiotics (Inj. Tazact and metrogyl) after sending the blood cultures. After correction of
dehydration, she was started on inoptrope. Next day, she was taken up for ERCP,
where papillotomy was done following that there was discharge of pus from the
papilla and 17F by 10 cms biliary stent was placed. After that she was shifted
to ward. Next day in the morning patient became drowsy, urea creatinine were
found to be raised. Iv fluids were given. Antibiotics upgraded to meronem emperically as blood culture came out to be sterile.
Central line was put and cvp was found to be 20 cms. ABG analysis revealed the
presence of metabolic acidosis. So she was taken up for hemodialysis. After
hemodialysis, she again developed hypotension, for which inotropes were
upgraded and patient was shifted to icu. She remained in ICU for 4 days
received hemodialysis daily along with broad spectrum antibiotics. After that,
her sensorium improved and spontaneous eye opening was present and was able to
follow commands with movements of limbs. Subsequently she was shifted to ward.
And after 15 days she could be discharged in hemodynamically stable condition.
TAKE
HOME MESSAGE-
1. Characterstic triad of
cholangitis (Charcot’s) is present only in 50 to 70 % and pentad (Reynold's) only in 20% of cases. So a high index
of suspicion in required for the diagnosis.
2. Fever although present in 90% of acute cholangitis patients, may be absent in elderly, immunocompromised and diabetic patients.
3. Most common cause of Cholangitis is choledocholithiasis.
4. Key to successful
management is early institution of broad spectrum antibiotics covering gram
negative (Most common offender being E. coli overall) and anaerobes, f/b
drainage of pus either externally (percutaneous drainage with pigtail catheter)
or internally (ERCP and stent placement)
5. Acute cholangitis can lead to multiple organ
failures quickly as seen in our case which has grave prognosis and requires supportive
treatment as well.
Any comment regarding the case or management is welcomed.
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