67 year old man presents 7 days post major surgery critically unwell. He has severe sepsis (high temp, compensated shock).

Investigations show:

Sepsis – high neutrophils (normal WCC), high CRP, elevated lactate

Abnormal LFT showing obstructive pattern (high GGT and ALP) with transaminitis (high ALT and bilirubin)

Normal synthetic function of liver (INR and albumin normal) – acute illness

Hb low – blood loss during surgery, sepsis

Causes:

Cholangitis (note absence of abdominal pain)

Other causes of painless jaundice with infection

Severe sepsis of any cause – exclude pneumonia, UTI, knee sepsis, peritonitis

This patient requires resuscitation, early antibiotics and investigation for source of sepsis with source control.

His CXR, UA were normal. Right knee was not clinically infected.

An abdominal CT was performed:

Note the large gallstone near the ampulla of vater causing obstruction with bile duct and hepatic duct dilation. This patient did indeed have  Cholangitis which required urgent ERCP under Gastroenterology.

This is an unusual case for two reasons:

1. Absence of abdominal pain

2. Previous Cholecystectomy

Cholangitis:

Charcot’s triad – Fever, RUQ pain and jaundice

Reynold’s pentad – Charcot’s triad plus hypotension and confusion