ZSFG 7/21 Intern Report: jaundice tables, cholangitis figures, owls oh my!

 

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 miss you 1

 

The (not exhaustive) list of possible Causes of Jaundice/Hyperbilirubinemia:

Causes of Conjugated Hyperbilirubinemia Causes of Unconjugated Hyperbilirubinemia
Extrahepatic cholestasis (biliary obstruction)

-Gallstones
-Intrinsic and extrinsic tumors (eg, cholangiocarcinoma, pancreatic ca) -Primary sclerosing cholangitis
– AIDS cholangiopathy
– Acute and chronic pancreatitis
– Strictures after invasive procedures
– Parasitic infections: liver flukes, Ascaris

Increased bilirubin production

– Extravascular hemolysis
– Intravascular hemolysis
– Dyserythropoiesis
– Wilson Disease

Intrahepatic cholestasis

-Viral hepatitis
– Alcoholic hepatitis
– Nonalcoholic hepatitis
– Primary biliary cholangitis
– Drugs and toxins: herbal meds, arsenic
– Sepsis and hypoperfusion states
– Infiltrative processes (amyloidosis, lymphoma, sarcoidosis, tuberculosis)
– TPN
– Cholestasis of pregnancy
Impaired Hepatic bilirubin uptake

– Heart Failure
– Portosystemic shunts
– Certain drugs: rifampin, probenecid

Rare Causes

-Rotor Syndrome: defect in reuptake of conjugated bilirubin
-Dubin-Johnson Syndrome: Defect of canalicular organic anion transport

Impaired bilirubin conjugation

– Gilbert’s (stress-induced, asymptomatic except mild bilirubin elevation)
– Crigler-Najjar syndrome
– Hyperthyroidism
– Liver diseases

 

What’s the anatomy and where does the obstruction occur to cause intra/extra-hepatic biliary dilation:
gb picobst

 

Awkward/borderline inappropriate ERCP* depiction:

ERCP
*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 🙂

 Evernote link: https://www.evernote.com/shard/s354/sh/3d628eb6-da73-4eef-a67f-aba26e6f61a4/afe2668d0fc4f6f0f69b69ac9932670a

 

 

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