60-year old woman with a fever and abdominal pain.

A 60-year old woman presents with a fever, which she has since 2 days. She has vague upper abdominal pain and feels nauseous. She feels like throwing up. The past 24 hours the fever’s gone up to 39,6° C and she’s shivering. Diuresis has decreased. She’s somewhat jaundiced, has a pulse of 112/min and blood pressure is 95/60 mm Hg. There’s little peristalsis and the right upper abdomen is painful on palpation.

Blood tests show a massive leukocytosis accompanied by a left shift. Other results include:

- haemoglobin: 6,9 mmol/l
- sodium: 140 mmol/l
- potassium: 6,2 mmol/l
- bicarbonate: 18 mmol/l
- glucose: 5,3 mmol/l
- creatinine: 500 mmol/l
- urea: 40 mmol/l

ECG reveals spiked T-tops. Chest X-ray is normal.

Questions:

1. What investigations should be done?

2. What therapeutic measures should be taken directly?

 

1. Aminotransferase (ALT, AST), Gamma glutamyl transferase, Alkaline phosphatase, Amylase, CRP, Bilirubin, PT, PTT, coagulation factors, Abdominal X-ray and ECHO (ultrasound), blood culture...

2. Antibiotics, Calcium gluconate and 10% glucose because of hyperkalemia, fluid resuscitation, surgery...

My diagnose is acute cholangitis.

 

Answers:

1.

To be sure what caused the decreased urine output, a urine sample is needed for a sediment analysis, culture and biochemical investigations (sodium, potassium, urea, creatinine and osmolality). This will help to differentiate between a prerenal (hypotension) and a renal cause (e.g. tubular necrosis). To rule out a postrenal cause, an ultrasound can be used (with which you can also check for gallstones, while you’re at it). Because of the fever and shivers, 3 blood cultures are necessary. Lastly, perform LFTs.

2.

For the hypotension, it’s necessary to give 0,9% saline IV. The hyperkalaemia (which caused the ECG-abnormality) can be treated by administering 250 ml glucose 20% and 20 units of fast-acting insulin. The cardiotoxic risk of the hyperkalaemia can be counteracted with 10 ml calcium gluconate 10% and by giving 100 ml sodium bicarbonate 1,4% for the acidosis (objectified by the low bicarbonate). Because sepsis is very likely, antibiotics have to be given. What antibiotic depends on its nefrotoxic effects (if there are any). Also, the dosage has to be adjusted to the kidney function.

Literature:

’Klinische nefrologie’ (De Jong et al.) (4th edition); a Dutch medical book on nephrology.

Note.

In the book, it didn’t say that LFTs should be performed, but in my opinion it was useful to determine how serious potential liver damage was.