67 year old man presents 7 days post major surgery critically unwell. He has severe sepsis (high temp, compensated shock).
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
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
Charcot’s triad – Fever, RUQ pain and jaundice
Reynold’s pentad – Charcot’s triad plus hypotension and confusion