Cholangitis

A 55 year old female presented with pain in upper abdomen since 10 days , a/w breathlessness. Usg was s/o mild gb wall thickening and multiple calculi in gb. Serum bilirubin was 4.9 and shot sgpt were above 300 , alp was above 400. Usg showed no CBD dilatation and no ihbrd. Patient was in shock and aki. Patient intubated and inotropic support started and shifted to ICU. Inotropes now tapered off and urine output is now normal. Patient is currently running fever upto 103F. Tlc are 25,000 and PCT is >20. Blood culture is sterile. Patient was planned for cholecystostomy but review usg by interventional radiology team showed no gb distension or evidence of empyema, normal CBD and no IHBRD, so procedure was deferred. The same usg showed heterogeneity in segment 5 & 8 and 2-3 evolving cholangitic microabscesses. Repeat LFT's showed bilirubin 3.4 , ot , pt and alp showed decline. Patient is on meropenem , tigecycline and metronidazole. Vitals are stable. Only issue is high grade fever. Any suggestions regarding investigations or change in treatment plan ???

(Edited)
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Although clinical picture is that of REYNOLDS PENTAD With 1.Right upper quadrant pain 2.Jaundice . 3.Fever with rigors 4.Shock - low blood pressure and tachycardia 5.Mental confusion . But USG shows no stone in CBD - although s.alkaline phosphatase is above 400 which is indicative of obstructive jaundice. May be either a small calculus in CBD might have passed in duodenum and sometimes a small calculus particularly in retroduodenal part may not be picked up by USG . A CT scan may help or a MRCP which is non - invasive than ERCP in this case may help . Meanwhile treatment is on expected lines and continue same treatment along with UDCA 300 mg B.D till the jaundice settles . Plan for elective cholecystectomy after 6 - 8 weeks
Thank you doctor
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All the features presented like leukocytosis, high rise of temperature and pt in shock on pt of gall bladder stone due to septicaemic condition leading to deranged liver enzymes with infective bacterial hepatitis . This further leading to oedema of the hepatic cell causing jaundice and ascending colangitis Treatment as you are treating in ICU protocol with inj Meropenem Inj metronidazole As vitals are normal I think pt has overcome the crisis

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