A few pictures and pearls to feast on from intern report today where we discussed the case of an older man with acute cholangitis due to biliary obstruction from newly diagnosed pancreatic adenocarcinoma.
Also, congrats interns on completing your first block of the year!
Great work and
The (not exhaustive) list of possible Causes of Jaundice/Hyperbilirubinemia:
|Causes of Conjugated Hyperbilirubinemia||Causes of Unconjugated Hyperbilirubinemia|
|Extrahepatic cholestasis (biliary obstruction)
|Increased bilirubin production
– Extravascular hemolysis
– Intravascular hemolysis
– Wilson Disease
– Alcoholic hepatitis
– Nonalcoholic hepatitis
– Primary biliary cholangitis
– Drugs and toxins: herbal meds, arsenic
– Sepsis and hypoperfusion states
– Infiltrative processes (amyloidosis, lymphoma, sarcoidosis, tuberculosis)
– Cholestasis of pregnancy
|Impaired Hepatic bilirubin uptake
– Heart Failure
-Rotor Syndrome: defect in reuptake of conjugated bilirubin
|Impaired bilirubin conjugation
– Gilbert’s (stress-induced, asymptomatic except mild bilirubin elevation)
What’s the anatomy and where does the obstruction occur to cause intra/extra-hepatic biliary dilation:
Awkward/borderline inappropriate ERCP* depiction:
*Endoscopic retrograde cholangiopancreatography: a procedure that combines upper gastrointestinal (GI) endoscopy and x rays to evaluate and treat all those pesky bile and pancreatic duct problems
Duration of abx for acute cholangitis:
-Many subspecialty societies/expert opinion websites consider the options of 7-10 days (for most run-of-the-mill cholangitis with source control) vs 14 days (a la abx courses for some cases of bacteremia) in light of this patient having 2/2 blcx’s positive for E. coli, the bug presumed to cause his acute cholangitis.
–In discussing with our ZSFG ID expert, Lisa Winston, a 10 day course of abx (IV then transition to PO based on susceptibilities) seems most appropriate in this pt’s case.
-Taking into account the stability/clinical status of the patient, whether or not there’s source control, and the susceptibilities of the bug that ultimately grows are the most important factors here in coming up with the right abx course duration…and pretty much in any other case 🙂