Case history
Case history #1
A 65-year-old woman presents to the emergency department with a 2-day history of progressive right upper quadrant (RUQ) pain that she rates as 9/10 in severity. She reports experiencing fever, and being unable to eat or drink due to nausea and abdominal pain at baseline, exacerbated by food ingestion. Her bowel movements are less frequent and have become loose. Her pain is not relieved by bowel movement and is not related to food. She has not taken antibiotics recently nor does she use nonsteroidal anti-inflammatory drugs or drink alcohol. On exam, she is febrile at 102.9°F (39.4°C); supine BP is 97/58 mmHg; standing BP is 76/41 mmHg; heart rate is 127 bpm; and respiratory rate is 24 breaths per minute with normal oxygen saturations. Her exam is remarkable for scleral and sublingual icterus, tachycardia, RUQ pain with no rebound, and involuntary guarding on the right side. Fecal occult blood test is negative. Laboratory results show a WBC of 18,000/microliter (reference range 4800-10,800/microliter) with 17% (reference range 0% to 4%) bands and polymorphonuclears (PMNs) of 82% (reference range 35% to 70%). Aspartate aminotransferase (AST) is 207 units/L (reference range 8-34 units/L), alanine aminotransferase (ALT) is 196 units/L (reference range 7-35 units/L), alkaline phosphatase is 478 units/L (reference range 25-100 units/L), total bilirubin is 6.3 mg/dL (reference range 0.2 to 1.3 mg/dL), and amylase is 82 units/L (reference range 53-123 units/L).
Case history #2
A 58-year-old man with pancreatic adenocarcinoma, who had a plastic stent placed in his common bile duct 6 weeks ago to relieve obstructive jaundice, presents to the emergency department with a 1-week history of progressive nausea and occasional vomiting after eating. He has generalized abdominal pain that is worse in the RUQ. He has experienced subjective fever/chills and states that his bowel movements are pale. Laboratory results show a WBC of 14,000/microliter (reference range 4800-10,800/microliter) with 8% (reference range 0% to 4%) bands and PMNs of 77% (reference range 35% to 70%). AST is 214 units/L (reference range 8-34 units/L), ALT is 181 units/L (reference range 7-35 units/L), alkaline phosphatase is 543 units/L (reference range 25-100 units/L), total bilirubin is 10.7 mg/dL (reference range 0.2 to 1.3 mg/dL), and amylase is 110 units/L (reference range 53-123 units/L).
Other presentations
Older patients, typically defined as those aged 60 years or older, may present with nonspecific and nonlocalizing signs and symptoms. Patients may also present with sepsis and mental status changes, and are often too ill to localize their pain.[2] Some patients with cholangitis, and less commonly sepsis, may have deceptively normal vital signs until late in their clinical course.[3]
Ascaris lumbricoides infection leading to cholangitis has an atypical and varied presentation compared with cholangitis caused by a stone.[4] While up to 25% of patients will present with classic signs and symptoms of cholangitis, many patients present with nonspecific findings such as nausea, vomiting, and generalized abdominal pain.[5]
Recurrent oriental pyogenic cholangitis, also known as oriental cholangiohepatitis, is characterized by recurrent attacks of abdominal pain, fever, and jaundice.[6] The disease is endemic to South-East Asia, and is classically associated with intrahepatic stone disease that is recurrent and recalcitrant to therapy.[6] Parasitic infection of the biliary tree may play a role in this condition.[6] In contrast to cholangitis from choledocholithiasis, endoscopic therapy is rarely curative and a combined endoscopic, radiologic, and surgical approach is often required to treat recurrent stone formation and associated episodes of obstruction and cholangitis.[6][7]
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