Case Presented by Brett Sorge, MD
CHIEF COMPLAINT(S): Chest pain and SOB
HISTORY OF PRESENT ILLNESS:
This is a 67 yo male with HTN, hyperlipidemia and DM who presents with chest pain. His chest pain started this morning (14 hours ago) and is pressure-like and located around the center of his chest. The pain does not radiate, and has not gone away. He is having SOB as well, and feels like he has worse pain with deep breaths. He has had chills since this morning. He has had nausea and vomiting starting today as well. He has had four episodes of non-bloody vomiting total. He admits to a separate epigastric pain as well, that is worse with defecation. The pain does not radiate, and comes and goes. Previous to this morning, he had been tolerating diet with no N/V. He has had pale colored stool ever since a cholecystectomy 3 months ago and has noticed “Vernors”-colored urine. He denies skin changes, itching, or yellowing of his eyes. He denies recent travel, smoking, cough, diarrhea, bright red blood per vomit/rectum, history of cancer or blood clots.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No weight loss.
HEENT: No loss in vision, No runny nose.
SKIN: No rash
GASTROINTESTINAL: No black or bloody stools.
GENITOURINARY: No burning on urination.
NEUROLOGICAL: No syncope
MUSCULOSKELETAL: No loss of muscle function.
HEMATOLOGIC: No history of easy bruising.
LYMPHATICS: No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINE: No polyuria or polydipsia.
ALLERGIES: No history of asthma.
PMD: Patient says he goes to an outside provider for his primary care
PAST MEDICAL HISTORY: Hyperlipidemia, hypertension, diabetes
SURGICAL HISTORY: Cholecystectomy 3 months ago, s/p laparotomy from GSW 30 yrs ago
MEDICATIONS: Patient does not know medications he takes – EMR- metoprolol 50 QD, amlodipine 5 mg QD, losartan 100 QD, atorvastatin 40 QHS, pioglitazone 45 QD
SOCIAL HISTORY: Denies smoking cigarettes, drink alcohol, drug use
FAMILY HISTORY: No family history of early MIs
General: Laying in bed, appears uncomfortable.
Vitals: Blood pressure 215/94, pulse 90, respirations 16, temperature 38.1. Pulse oximetry 100% on room air
HEENT: Head exam was generally normal. No scleral icterus. Mucous membranes were moist.
Cardiovascular: Regular rate and rhythm, no murmurs rubs or gallops
Respiratory: Clear to auscultation bilaterally
Gastrointestinal: Tender to palpation of the epigastric area, soft, non-distended, + BS, multiple scars from previous surgeries
Musculoskeletal: Able to move all extremities
Neurologic: Neurologically, the patient was awake, alert, and oriented to person, place and time. There were no obvious focal neurologic abnormalities. No asterixis or tremor noted.
BMP – 138/3.7/103/25/14/0.86/158 Ca – 9.6
LFT – ALT-724, AST-1637, Alk Phos – 379, t bili – 2.2, d bili – 1.4
Lipase – 63, Ammonia – 69, Lactic Acid – 2.6
CBC – 15.4/13.5/41.7/251
Coags – 23.1, 11.3, 1.06
Troponin – <0.017
EKG – normal
CXR – normal
US RUQ- dilated common bile duct without signs of stone, abscess, or an intra-hepatic process
1. What is the most common symptom in ascending cholangitis?
D. RUQ pain
2. What is the mortality without surgical decompression after 72 hours?
3. Of the answers provided, which antimicrobial therapy is best for empiric therapy for severe cholangitis?
C. ceftriaxone and metronidazole
Answers: 1. C, 2. D, 3. C
Many patient’s who present with ascending cholangitis present without classic signs and symptoms. Classically, patients would present with RUQ pain, fever and jaundice. However, some recent studies have shown that these symptoms may only be present 15-20% of the time. The key symptom is fever, which is present in 90% of patient’s. Factors that play a role in the pathogenesis of the disease involve an obstruction or an increase in luminal pressure that leads to a bacterial infection. Risk factors include stones, recent cholecystectomy, ERCP, history of cholangitis, or HIV. Bacteria are thought to invade the obstructed biliary tree in a retrograde fashion. The most common bacteria involved are E coli, klebsiella, enterococcus, and bacteroides. Work-up will show elevated WBC in 79% of patients, with LFT’s indicating cholestasis, with hyperbilirubinemia and an increased alkaline phosphatase level. The most common sign on ultrasound will be a dilated common bile duct which is only present 64% of the time. If there is a high clinical suspicion the patient can be taken for ERCP for both diagnosis and therapy. Empiric anti-microbial therapy should be aimed at treating gram negative, gram positive and anaerobic bacteria. Drainage and decompression are required, with a mortality rate approaching 100% if this is delayed 72 hours.