A 45 - year - old woman presenting

with severe right upper quadrant

pain and jaundice
Mrs Emma Watson is a 45 - year - old artist who presents with a 2 - day history of right
upper quadrant pain and jaundice.
She has noticed her stools are light and her urine is a darker colour than usual.
She has been seen in the emergency department and you have been asked to review her.
On examination she is apyrexial, in pain and distressed.
Her blood pressure is 130/80 mmHg and pulse is 80 beats per
minute.
She has mild tenderness in the right upper quadrant but no rebound or guarding.
Blood tests have returned and show the following:
Bilirubin 79 μ mol/L
ALT 67 iU/L
ALP 587 iU/L
Albumin 39 g/L
γ - GT 784 U/L
 What pattern of abnormality is
seen in her blood tests?
• She is jaundiced as evidenced by a raised
bilirubin.
• The alkaline phosphatase and γ - GT are
elevated suggesting that the problem is biliary
in nature (i.e. a cholestatic jaundice).
• This may occur due to extrahepatic or
intrahepatic biliary disease although her
history of pain is suggestive of an extrahepatic
cause.
 What diagnoses would you wish to
consider at this stage?
The important diagnoses to consider are:
• Posthepatic jaundice from gallstones: A gallstone can cause an obstructive picture if it
becomes lodged anywhere from the gallbladder to the ampulla of Vater (Fig. 3.1).
• Cholecystitis: Infl ammation of the gallbladder can present acutely with pain and
derangement of liver function tests (Box 3.1 ).
• Gallstone pancreatitis: Acute pancreatitis can be precipitated by gallstones becoming
lodged in the common bile duct and is an indication for urgent endoscopic
intervention.
• Perforated viscus: The other differentials for severe abdominal pain should be
excluded, e.g. a perforated peptic ulcer, appendicitis, kidney stones, etc. Rarely, a
gallstone can erode through the biliary tract and present as a perforation. If the
gallstone reaches the small bowel it can cause obstruction or gallstone ileus (Fig.
3.2 ).
• Chronic biliary obstruction: If the history was over a longer period of time other
causes of obstruction (e.g. stricture to the common bile duct, cholangiocarcinoma
and a tumour in the head of the pancreas) should be considered. Sometimes these
cases present acutely when an asymptomatic chronic obstruction reaches a critical
aperture of bile duct narrowing.
 What are the next steps in
management of this woman?
• Ensure adequate resuscitation: As with the management
of any acutely unwell patient the first step is to check that her
airway, breathing and circulation are not compromised.
Establishing early intravenous access is a prudent measure
in this scenario in view of the early differential diagnoses.
• Analgesia: Treating her pain is an important early
intervention and intravenous analgesia may be the most
effective way of dealing with this quickly. Opiates can
theoretically increase biliary pressure and spasm and often
non- steroidal anti- infl ammatory drugs (NSAIDs) in
combination with antispasmodics are used to relieve pain.
 What are the next steps in
management of this woman?
• Further investigations:
-Amylase: to exclude pancreatitis.
-Efect chest X- ray (CXR): the presence of
subdiaphragmatic air should alert you to the possibility
of perforation.
-An urgent ultrasound scan: this will give information on
whether the biliary system is dilated or not.
Ultrasound may miss the presence of stones in the
common bile duct but the presence of intrahepatic
duct dilatation in the context of this case would
strongly suggest biliary obstruction.
 Features of cholecystitis
• Pain: the classic description of biliary colic is of pain radiating
around like a band from the back. Pain may be elicited on
palpation in the right upper quadrant (Murphy ’ s sign)
• Sepsis: pyrexia, raised white cell count or C – reactive protein
• Deranged liver function tests: an inflamed gallbladder often does
not cause jaundice as it does not impair bile flow. If a gallstone
becomes lodged in the cystic duct, however, this can impair bile fl
ow in the common bile duct and result in jaundice (Mirizzi ’ s
syndrome (see Fig. 3.1 ))
• Gallstones are the commonest cause of cholecystitis but it can
occur in their absence (acalculous cholecystitis) as a result of
ischaemia
 What further investigations can be
helpful in the assessment of patients
with obstructive jaundice?
• Magnetic resonance cholangiopancreatography
(MRCP) can give better resolution of the biliary
tree than ultrasound. It is a safer modality than
endoscopic retrograde cholangiopancreatography
(ERCP) for the diagnosis of gallstones.
• Endoscopic ultrasound (EUS) can be useful in
diagnostic uncertainty to detect gallstones in the
common bile duct.
• Mrs Watson ’ s amylase is normal and an erect
CXR does not show any evidence of free air.
• An urgent ultrasound is arranged and shows
dilated intrahepatic bile ducts (Fig. 3.3 ) and a
filling defect in the mid common bile duct
suggestive of a large gallstone.
• On arrival back on the ward you are urgently
called. Her blood pressure is 90/60 mmHg with a
pulse rate of 100 beats per minute and her
temperature is 38.5 ° C.
 What is the most likely cause of her
deterioration?
• The most likely cause is ascending cholangitis.
• She has evidence of Charcot ’ s triad (fever,
jaundice and right upper quadrant pain) which
is characteristic of this very serious condition.
 How would you mange her now?

Resuscitation
She is showing signs of shock. She needs resuscitation using the basic
principle of airway, breathing and circulation:
• High dose oxygen.
• Ensure adequate intravenous access and commence intravenous
fluids.
• Insert a urinary catheter to monitor urinary output.
• Monitor the response to bolus intravenous fluids.
Consider the need for invasive monitoring of her central blood
volume (CVP lines) if the blood pressure and pulse do not respond.
• Consider where the best environment is for her to be managed;
consider transfer to a high dependency unit.
Antibiotic therapy
Blood cultures are taken to identify the
organism responsible for her infection and to
determine sensitivities to antibiotics. Broad
spectrum antibiotics should be commenced.
The likely organisms that cause infection in the
biliary tree are shown in Table 3.1 .
It is important to use an antibiotic that will cover
Gram - negative organisms.
Mrs Watson responds to intravenous fluid therapy. Her blood pressure is now
120/80 mmHg and pulse 70 beats per minute.
She has a good urine output.
Blood cultures have been sent and antibiotic therapy with intravenous
cephalosporin and metronidazole commenced.
You are asked to look at some blood tests which were sent when she
deteriorated:
Bilirubin 160 μ mol/L
ALT 187 iU/L
ALP 798 iU/L
Albumin 36 g/L
γ - GT 784 U/L
Hb 14.8 g/dL
WBC 14.4 × 10 9 /L (neutrophilia)
Plt 478 × 10 9 /L
 How should she be managed now?
• Sepsis can cause a further deterioration in liver
function tests per se .
• However, her obstructive picture has worsened.
• The major concern here is that she has an
obstructed biliary system which is now infected.
• Without prompt drainage she may deteriorate
further.
• ERCP could alleviate the obstruction (Box 3.2 ).
• Mrs Watson has an urgent ERCP performed.
• This confirms the presence of a gallstone in the
common bile duct (Fig. 3.4 ).
• A sphincterotomy is performed and the
gallstone is removed (Fig. 3.5).
• Over the next few days her liver function tests
improve .
 What is the long - term plan?
• Although Mrs Watson has had a
sphincterotomy and had drainage she will
need a definitive procedure to remove her
gallbladder.
• She undergoes an elective laparoscopic
cholecystectomy a few months later.
 CASE REVIEW
A 45 - year - old woman presented with right upper quadrant
pain with symptoms, signs and liver function tests suggesting
an obstructive jaundice.
Radiology revealed dilated intrahepatic ducts and a fi lling
defect in the common bile duct.
She developed sepsis with circulatory compromise and was
resuscitated.
Treatment was initiated with broad spectrum intravenous
antibiotics.
An urgent ERCP was performed and this relieved the
obstruction with resolution of her symptoms and liver
function tests.
 KEY POINTS
• The presence of right upper quadrant pain associated with jaundice
is highly suggestive of gallstones. Other causes of obstruction
along the extrahepatic biliary tree need to be excluded
• Imaging of the biliary tree is vital to provide a prompt and accurate
diagnosis
• Imaging modalities will range from easily accessible ultrasound to
specialised tests such as MRCP or endoscopic ultrasound
• An obstructed biliary system is prone to biliary stasis and the risk of
infection
• Ascending cholangitis is a medical emergency and requires prompt
resuscitation and antibiotic therapy
• Ascending cholangitis is an urgent indication for ERCP to alleviate
the obstruction and therefore treat the sepsis
• Long - term treatment for gallstones is cholecystectomy, which is
usually performed by laparoscopy