Mellow Yellow: Diagnosis and Management of Multifactorial Postoperative Jaundice.

Abstract

A 55-year-old Hispanic man, with a prior history of gastroesophageal reflux disease, fatty liver, and cholelithiasis, was evaluated in the emergency department with complaints of severe right upper quadrant pain that was triggered by food but not associated with any other gastrointestinal symptoms. One month prior, he had been evaluated by his primary care physician due to similar, but less severe and self-limited pain, undergoing an abdominal ultrasound that had revealed cholelithiasis without evidence of cholecystitis. At the time of admission to the hospital, he was afebrile and mildly icteric. His abdominal examination was notable for epigastric tenderness, without rebound or guarding. Laboratory tests were notable for a leukocytosis (17.3 K/lL) and mildly elevated serum liver enzyme concentrations (ALT 69 IU/L; bilirubin 3.2 mg/ dL) (Figs. 1, 2). A repeat abdominal ultrasound was reported as showing no evidence of gallbladder wall thickening or acute changes of cholecystitis, but a dilated common bile duct (CBD) at 10.7 mm. On the second hospital day, after initial management with IV fluids, antibiotics, and analgesics, he underwent an endoscopic retrograde cholangiopancreatography (ERCP) that revealed a mildly dilated CBD with intraluminal filling defects (Fig. 3). Sphincterotomy was performed; the entire biliary tree was swept of sludge, small stones, and pus, consistent with ascending cholangitis and choledocholithiasis (Fig. 4). Feeling better, he was subsequently discharged home with a prescription for oral amoxicillin–clavulanic acid. Two days later, he returned to the emergency department with complaints of fever, severe right upper quadrant pain, and jaundice. Computed tomography (CT) scanning showed acute cholecystitis due to an impacted stone in the gallbladder neck that was likely the cause of Mirizzi’s syndrome with resultant jaundice (Fig. 5). Oral amoxicillin– clavulanic acid was stopped, and intravenous ceftriaxone was initiated. He underwent laparoscopic cholecystectomy, duringwhich the gallbladderwas noted to be gangrenous; the right upper quadrant and the Morison’s pouch were extensively contaminated by pus. A percutaneous infra-hepatic drainage catheter was placed. Upon examination of the removed gallbladder, acute and chronic inflammation, ulceration, necrosis, and a 1-cm calculus were found. On postoperative day 2, he was noted to have worsening jaundice (Fig. 1). Repeat ERCP showed no bile leak and no residual stones after repeated balloon sweeps. On postoperative day 3, his symptoms had not improved; he reported severe right upper quadrant pain. He had persistent jaundice, with high fever and leukocytosis. His liver tests were minimally abnormal (ALT 73 IU/L) (Fig. 2). A repeat CT scan revealed a slightly enlarged liver and a 1.3 9 4.8 9 4.2 cm air-fluid collection in the gallbladder fossa. A CT-guided fine-needle aspiration of this fluid was performed, and another percutaneous drainage catheter was placed, terminating in the fossa (Fig. 6). & George Triadafilopoulos vagt@stanford.edu