A 65-year-old woman with history of DM and HT presented to the Accident and Emergency Department with abdominal pain and dizzness.
Temperature was 40 Celsius degrees, pulse 133 per minute in sinus rhythm, BP 77/45. There was vaguely localized abdominal tenderness and guarding over the periumbilical region. Blood test showed slightly raised ALT to 55 and ALP to 155; leukocytosis of 26 (90% neutrophil); urea 14 and creatinine 324. Because of worry about contrast nephropathy, only plain CT abdomen was performed, and was initially commented as normal. ICU was consulted for supporting this patient.
What was the cause of this sepsis?
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CBD stone impacted at papilla, causing cholangitis
The plain film showed presence of a shadow with calcified nidus at the decond part of duodenum. It should not be mixed up with vascular structure as IV contrast had not been used. It was not oral contrast as the shape of shadow was rather ovoid in shape and located independent of gravity.
In situation of very acute biliary obstruction or if the obstruction is incomplete as a result of liberal sphincteroromy in previous ERCP, the biliary system may appear not alarmingly dilated. A high index of suspicion is required.
This patient was rapidly stabilized after laparotomy + ECBD + T-tube insertion (failed ERCP removal of CBD stone)