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Stem A (painful obstructive jaundice — cholangitis)
A 55-year-old woman presents with 48 hours of RUQ pain, fever 38.9°C, and jaundice. BP 88/50, HR 120, confused. Bilirubin 6.2 mg/dL (conjugated high), ALP 520 U/L, ALT 90, WCC 18 × 10⁹/L. US: dilated CBD 12 mm, gallstones in gallbladder, no clear CBD stone seen.[1]
Stem B (painless progressive — for part d)
Separately, a 70-year-old man has 4 weeks painless progressive jaundice, pale stools, dark urine, pruritus, weight loss, and a palpable non-tender gallbladder.[7]
Questions
a) Stem A — syndrome name, clinical criteria, and severity score name with key elements. (3 marks)
Ascending (acute) cholangitis — Charcot triad (fever, jaundice, RUQ pain); Reynolds pentad adds hypotension + mental status change (severe).[1]
Tokyo Guidelines (TG18) diagnose and grade acute cholangitis. This patient has organ dysfunction (shock + CNS change) — the highest severity band. TG18 validation: 30-day mortality rises with severity grade; Grade II is the band in which early or urgent biliary drainage significantly lowers 30-day mortality.[1]
b) Immediate resuscitation with antibiotic choice/dose and definitive source control timing. (5 marks)
ABC, oxygen, large-bore IV access, lactate, blood cultures before antibiotics, aggressive crystalloid for septic shock, early critical care.[2]
Antibiotics: start empirical IV antimicrobials chosen by TG18 severity grade and community- versus healthcare-associated setting (Gomi: agents listed by class; de-escalate once isolates return). Name a local broad-spectrum agent (often piperacillin-tazobactam) rather than inventing a guideline milligram dose.[2]
Correct coagulopathy: parenteral vitamin K if INR high; FFP only if bleeding or an urgent procedure cannot wait.[6]
Biliary decompression urgently after resuscitation — preferably ERCP sphincterotomy ± stone extraction/stent for severe disease (not delayed for “cooling off” once resuscitated). If ERCP fails: PTBD. Later cholecystectomy for gallstone source when stable.[1]
c) Laboratory pattern distinguishing obstructive from hepatocellular jaundice. (2 marks)
Obstructive/cholestatic: conjugated bilirubin raised, ALP and GGT out of proportion, ALT/AST mild-moderate; dark urine, pale stools, pruritus. Hepatocellular: ALT/AST dominate; ALP milder. Mixed pictures occur — always integrate imaging.[7]
d) Stem B — diagnostic pathway and when to stent vs operate. (5 marks)
Suspect malignant distal obstruction (Courvoisier).[7] Pathway: LFTs + US (duct dilatation) → pancreas-protocol CT ± MRCP → tumour markers adjunct (CA19-9) → MDT.
- Resectable periampullary/pancreatic head, fit: consider upfront surgery; preoperative drainage selective (cholangitis, intense pruritus, delayed surgery, neoadjuvant chemotherapy)
- Unresectable/metastatic/unfit or neoadjuvant: ERCP SEMS
- Tissue via EUS-FNA before systemic therapy
- Pruritus: Beuers — itch in cholestasis can be a major QoL burden; candidate pruritogens include lysophospholipids and sulfated progesterone metabolites
Additional teaching points
Mirizzi syndrome: stone in cystic duct/Hartmann pouch compresses CHD — know as stone disease pitfall. Painless jaundice is cancer until proven otherwise — but stones can be painless in elderly; image everyone.[7]
References7ShowHide
- [1]Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos) J Hepatobiliary Pancreat Sci, 2018.PMID 29032610
- [2]Gomi H, Solomkin JS, Takada T, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis J Hepatobiliary Pancreat Sci, 2018.PMID 29090866
- [3]van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for cancer of the head of the pancreas N Engl J Med, 2010.PMID 20071702
- [4]Dumonceau JM, Tringali A, Papanikolaou IS, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline - Updated October 2017 Endoscopy, 2018.PMID 30086596
- [5]Beuers U, Wolters F, Oude Elferink RPJ Mechanisms of pruritus in cholestasis: understanding and treating the itch Nat Rev Gastroenterol Hepatol, 2023.PMID 36307649
- [6]Degrassi I, Leonardi I, Di Profio E, et al. Fat-Soluble Vitamins Deficiency in Pediatric Cholestasis: A Scoping Review Nutrients, 2023.PMID 37299454
- [7]Elmunzer BJ, Maranki JL, Gómez V, et al. ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures Am J Gastroenterol, 2023.PMID 36863037