MKSAP Quiz: A patient hospitalized with fever and rigors

A 48-year-old man with primary sclerosing cholangitis and ulcerative colitis presents to the hospital with fever, rigors, right-upper-quadrant pain, and leukocytosis. Blood cultures are pending. After giving IV saline and IV piperacillin-tazobactam, which next test is most appropriate?

A 48-year-old man is hospitalized with a fever and rigors. He has primary sclerosing cholangitis and ulcerative colitis. His only medication is mesalamine.

On physical examination, temperature is 38.6 °C (101.5 °F), blood pressure is 118/75 mm Hg, pulse rate is 95/min, and respiration rate is 18/min. Abdominal examination is notable for right-upper-quadrant tenderness to palpation. The remainder of the examination is normal.

Laboratory studies show a leukocyte count of 14,000/µL (14 × 109/L). Blood cultures are pending.

A 1-L bolus of intravenous normal saline is administered, and intravenous piperacillin-tazobactam is given.

Which of the following is the most appropriate test to perform next?

A. CA 19-9 measurement
B. Endoscopic retrograde cholangiopancreatography
C. IgG4 measurement
D. Percutaneous transhepatic biliary tube placement
E. PET scan

MKSAP Answer and Critique

The correct answer is B. Endoscopic retrograde cholangiopancreatography. This content is available to MKSAP 18 subscribers as Question 21 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.

Endoscopic retrograde cholangiopancreatography (ERCP) is the most appropriate next test for this patient. This patient with primary sclerosing cholangitis (PSC) presents with fever, rigors, right-upper-quadrant pain, and leukocytosis, all of which are consistent with bacterial cholangitis. Indications for ERCP in patients with PSC are bacterial cholangitis (as in this patient), increasing jaundice, increasing pruritus, or a dominant stricture seen on imaging. Symptoms of bacterial cholangitis, increasing jaundice, and pruritus can signify strictures that may improve with dilation or stenting, or, alternatively, removing sludge or stone debris in the bile ducts via ERCP. A dominant stricture in a patient with PSC must be evaluated for cholangiocarcinoma by obtaining biliary brushings for cytologic examination, and, if available, fluorescent in situ hybridization to evaluate chromosomal abnormalities.

The CA 19-9 level will be elevated in the setting of bacterial cholangitis. The risk for false-positive results makes CA 19-9 measurement inappropriate in this context. CA 19-9 levels can be used as an adjunctive tool in the diagnosis of cholangiocarcinoma, but the diagnosis cannot be made based only on this marker.

IgG4 levels should be checked in patients with a new diagnosis of presumed PSC because IgG4 cholangitis is a steroid-responsive condition, whereas PSC is not. Testing for IgG4 does not assist in the management of this patient's cholangitis.

A percutaneous transhepatic biliary tube can be employed when ERCP is unsuccessful at traversing a biliary stricture, but because of its invasiveness and inconvenience, it would not be a first-line tool for assessing and treating a patient with bacterial cholangitis.

The role of PET in the evaluation and management of cholangiocarcinoma is evolving. However, this is not the test of choice in a patient with bacterial cholangitis because it does not allow for biliary intervention. Furthermore, PET scans can be associated with false-positive results for malignancy in the setting of bacterial cholangitis, and also with false-negative results due to the desmoplastic reaction of cholangiocarcinoma tumors.

Key Point

  • Indications for endoscopic retrograde cholangiopancreatography in patients with primary sclerosing cholangitis are bacterial cholangitis, increasing jaundice, increasing pruritus, or a dominant stricture on imaging.