Cagayan valley medical center

department of surgery

Clinical case discussion

PGIs JIs
Concha, Joshua Vincent Pad-eng, Diana Chantal
Daluping, Daphne Pagdilao, Klarizsa Joy
Dela Cruz, Desiree Jolly Palatan, Joana Marie
Ranjo, Johana Pallingayan, Maria Louisa
Vishwakarma, Rajat Kumar
GENERAL DATA
Name AC

Age 51 years old

Sex Female

Address Ilagan City, Isabela

Birthdate May 7, 1970

Birthplace Tuguegarao city, Cagayan

Civil Status Widow

Occupation Unemployed

Nationality Filipino

Religion Roman Catholic

Date & Time of Admission August 3. 2021 at 4:00 pm

Chief complaint

Right upper
quadrant
abdominal pain
History of present illness

1 WEEK PTA
● Sudden onset of pain on the RUQ
radiating to the back
● Lasted for several hours
● Aggravated by intake of food
● Mefenamic acid- no relief
● No consultation
History of present illness

3 DAYS PTA
● RUQ pain radiation to the back
● Jaundice, fever and anorexia
● Paracetamol
● No consultation done
History of present illness

FEW HOURS PTA

● Persistence of above symptoms
prompted consult and subsequently
admitted
Past medical history
Childhood illness Unremarkable

Medical history Cholelithiasis (2019); No procedure done

Surgical history Unremarkable

allergies Unremarkable
Family history

● Diabetes mellitus- Mother

● Hypertension- Mother and Father
● No family history of anemia, heart disease, CVD,
asthma, cancer
Personal and social history
Alcohol/DRug use
● Occasional alcoholic drinker, 1 bottle of beer (330 mL)
● Denies illicit drug use

Smoking history 5 pack years

Exercise and diet
●Physically inactive
●Eats 2-3 times a day; prefers meat and fried food; eats street
foods
REVIEW OF SYSTEMS
CONSTITUTIONAL (-) chills, (-) unintentional weight loss, (-) fatigue

SKIN (-) rashes, (-) lesions, (-) itching or dryness

HEAD (-) headache, (-) dizziness, (-) lightheadedness

EYES (-) pain, (-) redness, (-) excessive tearing, (-)

double/blurry vision
EARS (-) hearing loss, (-) tinnitus, (-) pain, (-) vertigo

NOSE (-) colds, (-) epistaxis, (-) nasal stuffiness, (-) sinus pain
REVIEW OF SYSTEMS
Mouth and throat (-) dentures, (-) bleeding gums, (-) mouth lesions, (-)
hoarseness
neck (-) pain, (-) stiffness
breast (-) lumps, pain, or discharge

Respiratory (-) cough, (-) shortness of breath, (-) dyspnea

cardiovascular (-) chest pain, (-) palpitations
gastrointestinal (-) dysphagia, (-) odynophagia, (-) constipation, (-)
diarrhea, (-) vomiting, (-) pale stools
REVIEW OF SYSTEMS
genitourinary (-) dysuria, (-) hematuria, (-) nocturia, (-)
oliguria, pale yellow urine
musculoskeletal (-) leg cramps, (-) swelling of extremities, (-)
joint tenderness
hematologic (-) easy bleeding, (-) easy bruising
endocrine (-) heat or cold intolerance, (-) excessive
thirst and hunger, (-) excessive sweating
Physical examination
general Awake, coherent, in cardiac distress, diaphoretic,
oriented to time, place, and person but moves
uncomfortably on bed

Vital signs ● BP: 100/60 mmHg

● Temperature: 39.0 C (Axillary)
● Respiratory rate: 20 cpm
● Heart rate: 102 bpm
● SPO2: 99%
● Wt: 67 kg
● Ht: 5’2’’
● BMI: 27 (Obese Type I)

skin (-) Pallor, (+) jaundice, (-) cyanosis; warm to touch, good
skin turgor
Physical examination
heent Head: Normocephalic, atraumatic
Eyes: Pink palpebral conjunctiva, icteric sclerae
Ears: No swelling, redness, tenderness and discharge
Nose: Septum at midline. No discharge. No sinus
tenderness
Mouth & throat: lips are not pale or cyanotic. Moist oral
mucosa. No buccal lesions. Tongue and uvula at midline.
neck Trachea at midline, no tenderness, no cervical
lymphadenopathy
breast No nipple retraction, no nipple discharge, no masses
Physical examination
Chest and lungs Symmetrical chest expansion, no retractions, no
tenderness upon palpation, clear breath sounds

HEART Adynamic precordium. Regular rhythm. No murmurs. No

palpable thrills. PMI at 5th ICS left midclavicular line.

Abdomen Flat abdomen; No scars or bruises. No distention and

visible pulsations noted. Normoactive bowel sounds; (-)
hepatomegaly; (+) direct tenderness on the right upper
quadrant area, (-) rebound tenderness; No masses
palpated; (-) Murphy’s sign,

extremities No edema, bruises or deformities. Capillary refill <2 sec

Diagnostic tests results
● hbt ultrasound: gallbladder non thickened, with
intraluminal 0.6 cm hyperdensity with acoustic
shadowing. Intrahepatic ducts are dilated. Common
bile duct is dilated at 1 cm. No pericholecystic fluid
seen.
● Hgb: 12.7 g/dl
● Hct: 45%
● wbc: 30, 950/ mm3
● platelet: 178 x10^9/L
Salient features

● Female ● Jaundice
● 51 years old ● Icteric sclerae
● Anorexia
● Ruq abdominal ● Nausea
pain ● history of cholelithiasis
● Fever (2019)
Differential diagnosis
Ascending cholangitis
Rule in Rule out
● 51/ Female Cannot totally rule out
● RUQ abdominal pain
● Jaundice
● Icteric sclerae
● Fever
● History of cholelithiasis
(2019)
● Tachycardic
● Anorexia
● Nausea
Acute cholecystitis
Rule in Rule out
● RUQ pain ● (-) Murphy’s sign
● Fever ● (-) Boa’s sign
● Tachycardic ● (-) palpable RUQ
● Anorexia mass
● Nausea
● Jaundice
Acute pancreatitis
Rule in
● RUQ pain
● (+) pain radiating to the back
● Fever
● Nausea
● (+) Abdominal tenderness
● Alcoholic beverage drinker
● (+) pain after food intake
● History of cholelithiasis
Rule out
● (+) jaundice
● (-) vomiting
● (-) Cullen’s sign
● (-) Grey Turner’s sign
● (-)steady, boring pain
● (-) palpable upper
abdominal mass
 initial impression

Ascending Cholangitis,
moderate; secondary to
Cholelithiasis
Admitting orders
● Admit patient to surgery ward under the service of
Dr. _____
● Secure consent for admission and management
● Vital signs every hour
● Diet: NPO
● IVF: D5LRS 1 x 8 hours
● Diagnostics:
CBC Amylase
Na, K, Ca Lipase
PT, APTT ALP
CRP AST, ALT, GGT
Creatinine Bilirubin
 Admitting orders

● Therapeutics:
Paracetamol 650 mg IV every 4 hours
Piperacillin-Tazobactam 4.5 g IV every 6h
Ketorolac 30 mg IV every 6 hours for pain
● Insert IFC then connect to UB
● I&O every 4 hrs
● For ERCP
 Admitting orders
● Refer to IM for CP clearance prior to
procedure
● Send OR request
● Secure consent for procedure
● Inform OR/AROD
● Secure 2 units of PRBC properly types and
crossmatched for possible OR use
● Refer accordingly.
CASE DISCUSSION
Gallbladder
● pear-shaped sac, 7 to 10 cm long
● average capacity of 30 to 50 mL
○ When obstructed – contain up to
300 mL
● Located in a fossa on the inferior
surface of the liver
● Four anatomic areas of the gallbladder
○ Fundus
○ Corpus (body)
○ Infundibulum
○ Neck
CASE DISCUSSION
Gallbladder
● Blood supply
○ Cystic artery- branch of right hepatic artery
○ Cystic veins portal vein
● Lymphatic drainage
○ Cystic nodes celiac nodes
● Innervation
○ Parasympathetic- hepatic branches of the vagus nerve
○ Sympathetic- celiac plexus
CASE DISCUSSION
Bile Ducts
● Hepatic ducts
● Common hepatic duct
○ Length: 1-4 cm
○ Diameter: approx. 4 mm
● Cystic duct
○ Spiral valves of Heister
● Common bile duct
○ Length: 7-10 cm
○ Diameter: 5-10 mm
● Blood supply
○ Gastroduodenal and right
hepatic arteries
CASE DISCUSSION
Bile Formation and
Composition
● 500 to 1000 mL of bile a day
● HCl, partly digested proteins, fatty
acids- increases bile production
and flow
● Bile- composed of water, mixed
with bile salts and acids,
cholesterol, phospholipids,
proteins, and bilirubin
○ Primary bile salts- chocolate,
chenodeoxycholate
○ Secondary bile salts-
deoxycholate, lithocholate
CASE DISCUSSION
Gallbladder Function
● to concentrate and store hepatic bile
● to deliver bile in a coordinated fashion in response to a meal
● Fasting state- 80% of bile is stored in the gallbladder
● Sphincter of Oddi- tonic contraction facilitated gallbladder
filling
● CCK- released from enteroendocrine cells in the duodenum
in response to a meal
○ Major stimulant for gallbladder emptying
● VIP, somatostatin- potent inhibitors of gallbladder
contraction
CASE DISCUSSION

Gallstone Disease
● Present in between 10 and 15% of adults
● Risk factors:
○ Increasing age
○ Gender- women 3x more likely to develop gallstones
○ Diet, BMI, Ethnic background
○ Pregnancy, Crohn’s disease, medications such as
somatostatin analogues and estrogen-containing oral
contraceptives
CASE DISCUSSION

Gallstone Formation
● Classified by their cholesterol content-
cholesterol stones and pigment stones
● Cholesterol stones
○ 80% of gallstones
○ results from supersaturation of bile
with cholesterol
○ Cholesterol hypersecretion either
through increased intake or
dysfunctional processing
CASE DISCUSSION
● Pigmented stones
○ Dark because of calcium bilirubinate
○ Contain <20% cholesterol
○ Black stones- usually small, brittle and spiculated
■ Formed by supersaturation of unconjugated bilirubin
within the bile
○ Brown stones- usually < 1 cm, brownish-yellow, soft, mushy
■ May form secondary to bacterial infection and bile
stasis
■ Typically found in Asian populations
■ Assoc. with stasis secondary to A. lumbricoides or C.
sinensis infection
CASE DISCUSSION
Clinical Manifestations
● Chief symptom: RUQ or epigastric pain (biliary colic)
○ Constant, increases in severity over the 1st hour or so after a
meal and can last 1 to 5 hours
○ Radiates to the right upper back or between the scapula
○ Associated with nausea and vomiting
● PE may reveal mild RUQ tenderness during an acute episode of
pain
ASCENDING CHOLANGITIS
● is an ascending bacterial infection in association with
partial or complete obstruction of the bile ducts
● Gallstones are the most common cause of obstruction in
cholangitis
● Most common organisms:
○ E. coli
○ K. pneumoniae
○ S. faecalis
○ Enterobacter
○ B. fragilis
ETIOLOGY
● Stasis or obstruction of bile in the CBD results
in bacterial infection and cholangitis
● Most common cause: choledocholithiasis
● Other causes: ERCP, benign or malignant
stricture, parasitic infection, extrinsic
compression by the pancreas, A. lumbricoides
infection
 EPIDEMIOLOGY
● United states: 10-15 % population (cholelithiasis)
● Native americans and Hispanics: 60-70%
● 6-9 % diagnosed with acute cholangitis
● Male-to-female ratio is equal (Ahmed, 2018)
● Female and older patients most common (Schwartz)
● Median age: 50-60 years old
CLINICAL MANIFESTATIONS
● may present as anything from a mild, intermittent,
and self-limited disease to a fulminant, potentially
lifethreatening septicemia
● Charcot’s Triad
○ Fever
○ Epigastric or RUQ pain
○ jaundice
● can progress rapidly with the development of shock
and altered mental status (Reynold’s pentad)
PATHOPHYSIOLOGY
DIAGNOSTICS
TG18/TG13 DIAGNOSTIC CRITERIA FOR ACUTE CHOLANGITIS
● Fever and/or shaking chills
A. Systemic
● Laboratory data: evidence of inflammatory
Inflammation response
● Jaundice
B. Cholestasis
● Laboratory data: abnormal liver function tests
● Biliary dilatation
C. Imaging ● Evidence of the etiology on imaging (stricture,
stone, stent, etc. )

Suspected Diagnosis: one item in A + one item in either B or C

Definite Diagnosis: one item in A, one item in B and one item in C
 LABORATORY STUDIES

● CBC: Leukocytosis: In patients with cholangitis, 79%

had a WBC greater than 10,000/mL, with a mean of
13.6. Septic patients may be leukopenic.
● Liver Function Tests: results to be consistent with
cholestasis, hyperbilirubinemia (88-100%) and
increased alkaline phosphatase level (78%).
 LABORATORY STUDIES

● AST and ALT levels are usually mildly

elevated.
● Blood Cultures: obtained from bile or stents
removed at ERCP
● Procalcitonin: suggested as useful parameter
for severity assessment of acute cholangitis
IMAGING
1. ULTRASOUND
●Initial investigation for
suspected diseases of the
gallbladder and biliary tree
●to look for the presence of
gallstones, dilated ducts and
possibly pinpoint a site of
obstruction
IMAGING
2. ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY

●Definitive diagnostic test

●For sphincterotomy and stone removal
●Direct visualization of the ampullary region
●Direct access to the common bile duct with the
possibility of therapeutic intervention
IMAGING
3. PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY

●Useful in patients with bile duct strictures

or tumors, as it can define the anatomy of
the biliary tree proximal to the affected
segment
IMAGING
4. CT SCAN

● Shows the pancreatic and periampullary masses, if

present, in addition to the ductal dilatation
● Define the course and status of extrahepatic biliary
tree and adjacent structures
● For investigating cases of obstructive jaundice
(stone, tumor)
IMAGING
5. MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY

● is a noninvasive imaging modality that is used in the

diagnosis of biliary stones and other biliary
pathology.
● is accurate for detecting choledocholithiasis,
neoplasms, strictures, and dilations within the biliary
system.
IMAGING
6. ENDOSCOPIC ULTRASOUND (EUS)

● Requires special endoscope with an

ultrasound transducer
● For the evaluation of tumors and their
resectability
● Allows biopsies of tumor under ultrasound
guidance
Grading for acute cholangitis
GRADE I ( Mild ●Does not meet any criteria of grade II or III acute
cholangitis at initial diagnosis
Acute
Cholangitis )

GRADE II Acute cholangitis PLUS any two of the following:

( Moderate ● Abnormal WBC count (> 12,000/mm3 or < 4,000/mm3)
● Temperature (≥ 39°C)
Acute ● Age (≥ 75 years old)
Cholangitis ) ● Hyperbilirubinemia (Total serum bilirubin ≥ 5 mg/dL)
● Hypoalbuminemia (<STD x 0.7)
Grading for acute cholangitis
Acute cholangitis that is associated with the onset of
dysfunction at least in any one of the following
organs/systems:
● Cardiovascular dysfunction: hypotension requiring
treatment with dopamine ≥ 5 μg/kg/minute or any dose
of norepinephrine
GRADE III ● Neurologic dysfunction: idisturbance of consciousness
( Severe ● Respiratory dysfunction: PaO2/FiO2 ratio < 300
Acute ● Renal dysfunction: oliguria, serum creatinine > 2 mg/dL
Cholangitis ) ● Hepatic dysfunction: INR > 1.5
● Hematologic dysfunction: platelet count < 100,000/mm3
MANAGEMENT
 INDICATIONS AND TECHNIQUES FOR
ACUTE CHOLANGITIS
1. ENDOSCOPIC TRANSPAPILLARY BILIARY DRAINAGE
● First line drainage procedure
● Gold standard treatment for acute cholangitis
● 2 Types:
❖ Endoscopic Nasobiliary Drainage (ENBD) for
external drainage
❖ Endoscopic Biliary Stenting (EBS) for internal
drainage
 INDICATIONS AND TECHNIQUES FOR
ACUTE CHOLANGITIS

2. PERCUTANEOUS TRANSHEPATIC
CHOLANGIAL DRAINAGE
● indicated to the patients with an
inaccessible papilla due to upper
gastrointestinal tract obstruction
● Can be used as a salvage therapy
 INDICATIONS AND TECHNIQUES FOR
ACUTE CHOLANGITIS

3. SURGICAL DRAINAGE
● Open drainage for decompression of the
bile duct
● Extremely rare
TRANSFER CRITERIA FOR ACUTE CHOLANGITIS

● If a calculus is present in the common bile duct or

GRADE I ( Mild Acute there is no response to initial treatment (within 24
Cholangitis ) hrs), a similar response for moderate acute
cholangitis should be considered

● Patients should be treated in a hospital where biliary

GRADE II ( Moderate drainage and systemic management can be
Acute Cholangitis ) performed. If a hospital is not equipped to perform
biliary drainage, they should be transferred to a
hospital where this can be provided

● Patients who require emergency biliary drainage as

GRADE III ( Severe well as critical care should be transferred
immediately to a hospital where this can be
Acute Cholangitis ) provided.
prognosis
● Early biliary drainage: <10% mortality
● Early ERCP: lower 30-day mortality
● Poor prognostic factors:
● Advanced age, delayed decompression,
comorbidies: mortality rate at 17-40%
● Serum creatinine: > 2 mg/dL
● Platelet count: <100,000/mm3
● Leukocytosis: >20,000 cells/uL
● Total bilirubin: >10 mg/dL
Thank you!