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A 68-year-old man presents with 24 hours of right upper quadrant pain, fever, and new jaundice. BP 88/50, pulse 120, confused. Bilirubin 68 µmol/L, ALP markedly raised, ALT moderately raised. Ultrasound: dilated CBD, gallbladder stones, no free fluid.
Questions
a) Name the diagnosis using eponymous features and list immediate priorities with an antibiotic example. (4 marks)
Severe ascending cholangitis — Reynolds pentad = Charcot triad (RUQ pain + fever/rigors + jaundice) plus hypotension and mental status change.
Priorities: ABC/critical care, blood cultures, IV crystalloid, IV broad-spectrum antibiotics e.g. piperacillin-tazobactam 4.5 g every 8 h (or local equivalent covering Enterobacterales ± enterococci per protocol), correction of coagulopathy, and urgent biliary decompression — ERCP (percutaneous transhepatic drainage if ERCP unavailable/fails). Cholecystectomy is not the first procedure for cholangitis.
b) Contrast biliary colic, acute cholecystitis, and cholangitis (one discriminating line each). (3 marks)
- Biliary colic: severe episodic RUQ/epigastric pain usually lasting under 6 hours, afebrile, normal inflammatory markers, thin-walled stone-containing GB on US.
- Acute cholecystitis: constant pain often beyond 6 hours, fever, Murphy positive, wall thickening/pericholecystic fluid — cystic duct obstruction with GB inflammation.
- Cholangitis: Charcot triad from infected obstructed bile duct — jaundice + sepsis; needs duct drainage.
c) Mild gallstone pancreatitis — principles of supportive care and timing of cholecystectomy. (4 marks)
Supportive care: IV fluids, analgesia, early nutrition as tolerated, monitor for severity (organ failure).
ERCP only if concurrent cholangitis or persistent biliary obstruction — not routinely for all mild cases.
Once mild pancreatitis settles, perform laparoscopic cholecystectomy during the index admission to prevent recurrent biliary pancreatitis (delayed elective chole risks readmission).
d) Define Rigler triad and outline emergency surgery for gallstone ileus. (4 marks)
Rigler triad: small-bowel obstruction + pneumobilia + ectopic calcified gallstone (often impacted at ileocaecal valve) from cholecystoenteric fistula.
Emergency: resuscitate, then enterolithotomy (remove stone via enterotomy proximal to impaction); fistula takedown/cholecystectomy may be concurrent in fit patients or deferred as a second stage in frail patients.