RUQ pain x3 days, fevers x24h. LFTs are elevated. Which of these tests should you order?
A 64-year-old man presents to the emergency department complaining of 3 days of intermittent right upper quadrant pain, has had a fever for 24 hours, and a physical examination is notable for jaundice. He has no significant past medical history. What is the diagnosis and how should this patient be managed? Scroll through the slideshow above to learn more about this man's case and to see if your initial diagnosis was correct.
Patient history. A 65-year-old man with no significant past medical history presents to the ED with 3 days of intermittent right upper quadrant pain and 24 hours of fevers. His physical examination shows icteric sclera, jaundice, and right upper quadrant tenderness to palpation.
Lab results, physical examination. An abdominal ultrasound showed multiple small gallstones, but no gallbladder wall thickening or pericholecystic fluid. Common bile duct was dilated to 11 mm without apparent choledocholithiasis. He receives IV fluid resuscitation and antibiotics and you are called for consult.
What is the next step in management?A. Order magnetic resonance cholangiopancreatography (MRCP)
B. Request surgical consult for urgent cholecystectomy
C. Perform urgent endoscopic retrograde cholangiopancreatography (ERCP)
D. Place percutaneous cholecystostomy tube
Answer: C. Peform urgent ERCP. Charcot's triad, seen in the patient, classically consists of right upper quadrant abdominal pain, fevers, and jaundice; the concern is for acute cholangitis. Cholangitis usually occurs in the setting of biliary duct obstruction, such as in stone disease or stricture. As with all causes of sepsis, fluid resuscitation and IV antibiotics must be instituted promptly to prevent circulatory collapse.
Relieve obstruction, control infection. The next step would be to relieve the obstruction and obtain source control of the infection. The ERCP is a modality of choice in patients with high pre-test probability of choledocholithiasis, if the overall medical condition allows. If the pre-test probability for stones is intermediate, MRCP or EUS can be performed. Cholecystectomy is indicated only if there is evidence of cholecystitis without an accompanying stone in the bile duct.