Treatment
She was commenced on intravenous antibiotic Flucloxacillin to cover for infection of unclear source d. In addition to this, the Rheumatology team advised her to withhold methotrexate and Sulphasalazine during her inpatient stay.
On the 2nd day of admission, she was still symptomatic with ongoing vomiting and fever. The antibiotic was changed to Piperacillin and Tazobactam while awaiting blood culture results.
Stool analysis didn’t reveal any pathological findings. A decision was made to scan the abdomen of the patient presuming an abdominal source of infection.
CT scan of abdomen and pelvis was done on the 2nd day of admission which revealed dilated bile ducts. Common bile duct was 15mm in diameter, normally we would expect a size on not more than 10mm post cholecystectomy.3 The size was more than you would expect post cholecystectomy as shown in fig 1 and there was a double duct sign with pancreatic duct dilatation. MRCP which was done revealed stones in the cystic duct stump and distal CBD blunt transition zone as shown in fig. 2 and 3. Therefore, a diagnosis of cholangitis due to choledocholithiasis post cholecystectomy 4 was made based on MRI.