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.