I want to introduce you to Mrs. Catherine. The first time I met her, she was in an assisted living center and experiencing abdominal pain that had progressed over a few days. I had to wonder why she was in an assisted living center at such an early age, but the on-call nurse beat me to the question.
"Mrs. Catherine has dementia and has been mentally deteriorating pretty quickly, however She definitely does not seem herself today."
I walked in, introduced myself, and started to connect my cardiac monitor to get a set of vital signs. These were definitely not the vitals I was expecting..
Observing the elevated temp, tachycardia, and hypotension - my partner and I put sepsis high on the list of differentials.
I can remember a few times I had treated patients with similar symptoms... and it ended up being a urinary tract infection (UTI). Something about this was different though..
"Mrs. Catherine, can you tell me where your stomach hurts?"
She slowly moved her entire hand over the right upper quadrant. As I palpated the abdominal quadrants (saving the RUQ for last), she gasped as I gently compressed the RUQ. I remembered from my FP-C exam prep days that this response had a name. Murphy's sign is when you compress the right upper quadrant and have the patient take a breath. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive.
I couldn't help but notice how jaundiced her skin was. It reminded me of when my grandma was in the hospital with cirrhosis of the liver*.
*I remember wondering why her skin was turning yellow and googling it. I discovered that the yellow color comes from the breakdown of old red blood cells (bilirubin). The liver filters out the majority of the bilirubin by fecal excretion. Due to my grandma having liver failure, this process could not occur and it would accumulate in the bloodstream.
What would cause a systemic inflammatory response, pain in the RUQ, and jaundiced skin?
We started an IV, administered some balanced crystalloids, and routinely transported to a hospital 10 minutes down the road. Overall, the transport was uneventful, but what made this call memorable was how fast the doctor at the receiving facility made the diagnosis.
"Looks like Charcot's Triad, call gastroenterology for an ERCP and I will go put in an order for Zosyn."
The physician explained that the combination of right upper quadrant pain, elevated temperature, and jaundiced skin, is highly suggestive of cholangitis (Lee, 2009).
What is Cholangitis?
To familiarize ourselves with the biliary tree, I have simplified the anatomy in the illustration below. Essentially, the liver, gall bladder, and pancreas drain into the common bile duct. The common bile duct (CBD) will then drain into the duodenum to be excreted as feces. Can you think of some of the fluids that would be released through the CBD and into the duodenum?
From The Liver & Gall Bladder
Bilirubin - Waste from red blood cells
Bile Salts - Help us to absorb fat-soluble vitamin
From The Pancreas
Amylase - Breaks down starch and glycogen
Lipase - Breaks down fats
Let's pretend there is a stone in the gall bladder. After someone eats, the gall bladder will contract to excrete the bile into the CBD. If a stone is present, this contraction will cause irritation and pain to the gall bladder. However, that pain will subside after the contractions have stopped. This is biliary colic caused by cholelithiasis. Simply put, this is just the presence of a stone within the gall bladder. This is not a surgical emergency.. yet.
On the other hand, if that stone makes its way to the cystic duct and causes an obstruction, the gall bladder will continue to fill with bile from the liver and cause pain that is not relieved until the obstruction is cleared, This is called cholecystitis and is indeed a surgical emergency.
So why would either cholecystitis or cholelithiasis cause Catherine to be jaundiced and septic? It wouldn't. However, if that obstruction makes its way to the common bile duct and causes an obstruction, it will block all the content we listed above from draining into the duodenum (lipase, amylase, and bilirubin).
When obstruction of the CBD occurs, it is called choledocholithiasis. With the absence of bile flowing from the duct and into the duodenum, bacteria are able to ascend from the intestines and into the common bile duct (Ahmed, 2018). This, coupled with inflammation and increased ductal pressure, leads to a very serious condition called ascending cholangitis.
The presence of bacteria in such a highly vascular area creates a very dangerous situation in which bacteria is able to enter into the bloodstream (bacteremia). This is EXACTLY what was happening to Catherine. An obstruction in the common bile duct was preventing bilirubin from being released into the intestines, the bacteria ascending into the CBD caused the bacteremia and elevated temp, and the abdominal pain was caused by the increase in pressure and this inflammation within the biliary tree.
The treatment for this is possibly an abbreviation you may have heard before. It is called an endoscopic retrograde cholangiopancreatography (Mosler, 2011). It involves placing an endoscope through the esophagus and into the junction between the stomach and intestines (duodenum). A wire is then passed into the entrance of the common bile duct and a catheter follows over the wire. Contrast is injected through the catheter and into the biliary tree. The flow of this contrast is viewed under fluoroscopy (much like a cardiac cath procedure). If an obstruction is identified, a catheter can be placed past the obstruction, a balloon inflated, and the catheter is then withdrawn to scoot the stone out of the CBD and into the intestines for excretion.
What I took away from this case:
To be honest, knowing this information may not have changed a lot in the prehospital environment. I would have still started an IV and gave a reasonable fluid bolus either way. However, I do believe that early recognition and antibiotics could have a place in EMS. In my opinion, there is no reason a physician should nail a diagnosis within seconds, and it was not even on my radar. As a general rule for myself, any intervention that is done within the first 5 minutes of dropping off a patient, should have (if possible) been done by EMS. At my current program, we carry antibiotics for this exact reason. Presumed sepsis without antibiotic coverage is an indication to trigger administration.
Test your knowledge with the quiz below!
Here is a cool infographic Brian King created on this topic.
Peer Review:
Leon Eydelman, MD.
This is great! It is also worth mentioning magnetic resonance cholangiopancreatography (MRCP), which is almost always going to be the first thing done before ERCP. Especially if it isn't bankers hours and GI isn't around, and hepatobiliary imilodiacetic acid (HIDA) scan which confirm obstruction of the gallbladder.
Also a lot of times this is treated with percutaneous IR gallbladder drainage, as it is commonly accompanied with cholecystitis. Since you're doing point of care ultrasound, it's pretty bread and butter in hospital emergency medicine to do gallbladder ultrasounds and find common bile duct, not sure if that's too nerdy but you could definitely find POCUS images.
A podcast on this biliary emergencies will be released on Wednesday 9/8/21
References:
Ahmed M. (2018). Acute cholangitis - an update. World journal of gastrointestinal pathophysiology, 9(1), 1–7. https://doi.org/10.4291/wjgp.v9.i1.1
Lee JG. (2009) Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol. 2009 Sep;6(9):533-41. doi: 10.1038/nrgastro.2009.126. Epub 2009 Aug 4. PMID: 19652653.
Mosler P. (2011). Management of acute cholangitis. Gastroenterology & hepatology, 7(2), 121–123.
