A 58-year-old man presents to the emergency department with 2 days of fever, chills, and progressively worsening right upper quadrant abdominal pain. He also reports nausea and vomiting. His medical history is significant for gallstones and type 2 diabetes mellitus. He takes metformin and glipizide. His temperature is 38.5°C (101.3°F), blood pressure is 100/60 mm Hg, pulse is 105/min, and respirations are 22/min. On physical examination, he appears ill and jaundiced, and there is tenderness to palpation in the right upper quadrant with a positive Murphy sign.
Laboratory results show the following:
Total bilirubin: 8.0 mg/dL
Direct bilirubin: 5.8 mg/dL
Alkaline phosphatase: 820 U/L
Aspartate aminotransferase (AST): 110 U/L
Alanine aminotransferase (ALT): 95 U/L
Leukocytes: 18,500/mm3 with 82% neutrophils
Which of the following is the most likely finding on imaging of the abdomen?
The correct answer is:
A) Biliary dilatation
The patient's presentation of fever, jaundice, and right upper quadrant abdominal pain is consistent with acute cholangitis. This condition is commonly caused by biliary obstruction, often due to gallstones. The most likely finding on imaging in acute cholangitis is the dilation of the intrahepatic and extrahepatic bile ducts.
Answer choice B: Gallbladder wall thickening and pericholecystic fluid, is incorrect. Gallbladder wall thickening and pericholecystic fluid would suggest acute cholecystitis rather than cholangitis.
Answer choice C: Pancreatic edema and inflammation, is incorrect. Pancreatic edema and inflammation would indicate acute pancreatitis, not cholangitis.
Answer choice D: Short, annular strictures alternating with normal bile ducts, is incorrect. Short, annular strictures are indicative of primary sclerosing cholangitis, which does not fit the acute presentation.
Key Learning Point
In a patient presenting with fever, jaundice, right upper quadrant pain, and a positive Murphy sign, acute cholangitis is likely. The most likely finding on imaging is biliary dilation, most often secondary to biliary obstruction from gallstones.
