S1605 Recurrent Right Upper Quadrant Pain: An Atypical Presentation

Abstract

INTRODUCTION: Right upper quadrant (RUQ) pain is a common presentation in the ED however when labs are unremarkable but presentation is suggestive of cholangitis this can present a diagnostic dilemma. CASE DESCRIPTION/METHODS: A 51 yo South Asian male was admitted with acute RUQ abdominal pain and fevers for the past week. The pain was sharp, intermittent, 10/10, radiated to right shoulder and worse with deep inspiration. He reported a fever of up to 103F. This was associated with non-bloody emesis. He denied a history of gallbladder disease, change in stool, peptic ulcer disease or unintentional weight loss. He stated that he had multiple similar episodes over the past few years. On physical exam, vitals were BP 124/71, HR 69, T 96.9F and he had RUQ abdominal pain. Lab work was as follows: WBC (5 × 103/uL), Total BR (0.5 mg/dL), ALP (83 U/L), AST (40 U/L), and ALT (57 U/L). He had a CT two months prior to admission for similar presentation with findings of hepatic steatosis. Due to severity of abdominal pain, MRCP was done demonstrating dilatation of central and segmental intrahepatic biliary ducts with a linear filling defect in the distal common bile duct. Empiric antibiotics were started. Subsequent ERCP showed a severely dilated common bile duct and common hepatic duct, with biliary sludge which was removed on balloon sweep. CBD was successfully dilated and transpapillary sphincteroplasty was performed to allow better biliary drainage and to reduce future risk of recurrence. Antibiotics were continued after discharge for total of 10 days as well as ursodiol to reduce recurrence of stone and sludge formation. Review of outside records confirmed multiple episodes of cholangitis for which patient underwent ERCP. DISCUSSION: We present a case of recurrent pyogenic cholangitis with unremarkable labs on presentation despite finding of a filling defect on MRCP. It is characterized by intra-biliary stone formation due to bile stasis leading to biliary tree strictures and obstruction with recurrent attacks of cholangitis. It is most commonly seen in people who are from Southeast Asia with a peak prevalence in third and fourth decades of life. This case reflects the importance of quick diagnostic intervention in a patient with history of recurrent pyogenic cholangitis who initially presented with fever, abdominal pain, and normal labs on presentation. In particular, if suspicion is high imaging is necessary to ensure timely diagnosis and improve patient outcomes.