SHM Converge Scientific Abstract ePoster Gallery-A Case of Ascending Cholangitis Six Years Following Cholecystectomy

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This case describes a 57-year-old woman who developed presumed acute ascending cholangitis six years after cholecystectomy for gallstone pancreatitis. She presented with one day of right upper quadrant pain, nausea, vomiting, jaundice, fever, and a positive Murphy sign. Initial labs showed a marked hepatobiliary injury pattern with very elevated AST, ALT, alkaline phosphatase, and rising direct hyperbilirubinemia. She was started on piperacillin-tazobactam and admitted.<br /><br />CT abdomen/pelvis showed common bile duct dilation to about 1.0 cm, increased from prior imaging. Her abdominal symptoms improved spontaneously overnight, and by hospital day two her liver tests and bilirubin were downtrending. MRCP performed after symptom resolution again showed mild biliary dilation but no obstructing stone or mass. Because the imaging did not reveal a persistent obstruction and the patient was clinically improving, ERCP was deferred. She was discharged on levofloxacin and metronidazole with outpatient gastroenterology follow-up.<br /><br />The report emphasizes that acute cholangitis is usually diagnosed by systemic inflammation, cholestasis, and imaging evidence of biliary obstruction or dilation. This patient met the clinical and laboratory criteria, but imaging likely occurred after a stone had already passed, leaving only nonspecific post-cholecystectomy ductal dilation. The authors argue that her presentation was most consistent with a passed choledocholithiasis causing transient obstruction and infection.<br /><br />The discussion notes that choledocholithiasis after cholecystectomy is uncommon, and cholangitis in this setting is even rarer. Proposed risk factors include surgical clip migration, biliary strictures, older age, prior CBD stones, and periampullary diverticula, though a clear cause is often not identified.

Asset Subtitle

Raphael Rabinowitz

Meta Tag

Author List Eric Williamson, Joshua Kirschenbaum, Kyle Smith, Raphael Rabinowitz, Sohail Zahid, Somil Chugh

Category Clinical Vignettes

Concept Cholangitis

Concept Choledocholithiasis

Concept Systemic Inflammation

Concept Cholestasis

Concept Biliary duct dilation

Distinguished Non-Finalist

Presenter Organization NYU Grossman School of Medicine

Presenting Author Raphael Rabinowitz

Track Adult

Keywords

acute ascending cholangitis

choledocholithiasis

cholecystectomy

common bile duct dilation

right upper quadrant pain

jaundice

direct hyperbilirubinemia

MRCP

ERCP deferred

biliary obstruction

Cholangitis

Choledocholithiasis

Systemic Inflammation

Cholestasis

Biliary duct dilation