Critical management of severe obstructive cholangitis with septic shock in an elderly patient with cardiac and renal comorbidities

Vigneshwaran¹, Subadhra Devi², Maha Lakshmi³

¹Emergency Department Nurse, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

²Nurse Educator Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

³Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

Abstract

The critical management of obstructive cholangitis with septic shock in elderly patients with cardiac and renal comorbidities requires a multidisciplinary approach. Initial resuscitation involves stabilizing the patient’s airway, breathing, and circulation (ABCs) and administering broad-spectrum antibiotics. Urgent biliary drainage via Endoscopic Retrograde Cholangiopancreatography (ERCP) or Percutaneous Transhepatic Cholangiography (PTC) is crucial to relieve obstruction. Supportive care includes hemodynamic monitoring, renal replacement therapy if needed, and cardiac monitoring to manage comorbidities. A tailored approach considering the patient’s specific needs and comorbidities is essential to optimize outcomes.

Background

Obstructive cholangitis is a serious infection of the biliary tract that can lead to septic shock, particularly in elderly patients with underlying comorbidities such as cardiac and renal disease. Prompt recognition and treatment are crucial to prevent morbidity and mortality. The management of obstructive cholangitis involves a combination of antibiotics, biliary drainage, and supportive care. However, the presence of cardiac and renal comorbidities can complicate treatment and increase the risk of adverse outcomes. Effective management requires a multidisciplinary approach, considering the patient’s specific needs and underlying conditions.

Case Presentation

A 86-years-aged male with multiple comorbidities including type II diabetes mellitus, ischemic heart disease (post-PCI), chronic kidney disease, and a history of rectal cancer (post-chemotherapy) presented with fever and altered mental status. During transit, the patient experienced a cardiac arrest and was successfully resuscitated. Upon admission, investigations revealed severe obstructive cholangitis. Emergency Endoscopic Retrograde Cholangiopancreatography (ERCP) with Common Bile Duct (CBD) stenting and sludge clearance was performed. Post-procedurally, he developed septic shock and acute-on-chronic kidney injury, requiring intensive care, vasopressor support, and nephrology management.

Social History

He does not have any social history of cigarette smoking, alcohol or drug addiction.

Allergies

No known medicine or environmental allergies

Past Medical History

Type II Diabetes Mellitus

Coronary Artery Disease – double vessel disease, post-PCI

Chronic Kidney Disease (CKD)

Rectal Cancer – completed chemotherapy (records not available)

Physical Examination:

Vital signs Temp: 101.3- F, HR:102/min, RR:28/min, BP 90/60 mmHg, SpO2 :96%

A: Secured ETT, cuff pressure checked

B: PEEP and FiO2 titrate to adequate oxygenation

C: All peripheral pulse present. HR 102/min, BP 90/60 mm Hg, No pallor, icterus, or pedal edema

Neurological Examination: Assessed the level of consciousness, pain

sedation and analgesia: Titrate for comfort and safety.

Investigations

Alanine Aminotransferase (ALT/SGPT)	21.8 U/L
Calcium Serum	7.6 mg/dL
Creatinine	4.10 mg/dL
Gamma - Glutamyl Transferase (GGT)	122 U/L
Globulin	2.52 g/dl
Glucose	193 mg/dL
Indirect Bilirubin	0.75 mg/dL
K +	6.5 mmol/L
Magnesium	1.91 mg/dL
Phosphorous	3.6 mg/dL
Potassium	6.1 mmol/L
Sodium	132 mmol/L
Total Protein	5.38 g/dl
Urea Serum	184.04 mg/dL
Control (PT)	11.3 Seconds
Haematocrit	32 %
Haemoglobin	8.6 g/dl
Packed Cell Volume (PCV)	30.7 %
Platelet Count	263000 cells/µl
Test (PT)	31.2 Seconds
Total RBC Count	3.37 10^9/cumm
INR	2.79.
CA++(7.4)	0.95 mmol/L
Total Bilirubin	2.83 mg/dL

Imaging examination – MRCP images

The patient presented with a 3-day history of high-grade fever, chills, and rigor, followed by the sudden onset of altered sensorium and cardiac arrest. On arrival at the hospital, the initial differential diagnosis included obstructive jaundice with cholangitis.

Laboratory investigations revealed marked leukocytosis, indicative of a systemic inflammatory response, likely due to infection. Liver function tests (LFTs) showed evidence of hepatic dysfunction, and renal parameters were deranged, suggesting multi-organ involvement.

Despite the cardiac arrest, electrocardiogram (ECG) and echocardiography demonstrated preserved cardiac function post-resuscitation. Imaging studies identified biliary sludge and a possible biliary obstruction, corroborating the suspected diagnosis of obstructive jaundice secondary to ascending cholangitis.

This constellation of symptoms and findings is consistent with severe ascending cholangitis, which progressed to sepsis, multi-organ dysfunction syndrome (MODS), and cardiac arrest.

Management

1. Infection Control

Antibiotics – Broad-spectrum antibiotics to cover biliary pathogens.

2. Supportive Care

Fluid management – Careful fluid resuscitation to maintain organ perfusion.
Organ support – Support for liver and renal dysfunction.
Nutritional support – Adequate nutrition to support recovery.

3. Definitive Treatment

Biliary drainage – ERCP or PTC to relieve obstruction.

Surgical intervention – On 06.02.2025.

ERCP – CBD Stenting sphincterotomy, and sludge clearance performed. Selective CBD cannulation achieved. Confirmed by aspiration of bile. Cholangiogram not done, in view of cholangitis. With guide wire in deep IHBR, 7Fr x 10cm SF stent placed.

Impression: ERCP – CBD stenting done.

Post-procedural complications: Septic shock, requiring vasopressors and antibiotics

Monitoring – Close monitoring of organ function, infection control, and cardiac status.

Follow up treatment

Discharge Advice medication

S. No	Drug	Dose
1	Tab. Pantocid	40mg
2	Tab. Taxim O	200mg
3	Tab. Ursocol	300mg
4	Tab. N. Taur
5	Tab. Nodosis	500mg
6	Tab. Bunpro Forte

Skilled Nursing Care Plan

Comprehensive Monitoring and Assessment

Vital Signs: Hourly monitoring of temperature, BP, HR, RR, and SpO₂.
Neurological Checks: Regular GCS assessment for altered sensorium.
Cardiac Monitoring: Continuous ECG monitoring post-arrest.
Renal Function: Monitor urine output; report oliguria/anuria.
Lab Review: Ongoing assessment of WBC, LFTs, RFTs, ABG, and coagulation profile.

Medication and IV Therapy

IV Antibiotics: Timely administration as per prescription.
Fluid Resuscitation: Administer IV fluids/blood products per protocol.
Vasopressors/Inotropes: Administer and titrate if ordered for hemodynamic support.
Pain and Fever Management: Administer antipyretics and analgesics as needed.

Infection Prevention and Control

Aseptic Technique: Follow Strictly during all procedures (e.g., catheter care, IV lines).
Isolation Precautions: If required due to infection risk.
Wound/Line Site Monitoring: Inspect for signs of local infection.

Supportive and Specialized Care

Respiratory Support: Oxygen therapy, suctioning, or ventilator care if intubated.
Nutrition: Monitor for NPO status or initiate enteral/parenteral nutrition.
Renal Support: Monitor for dialysis needs and assist during procedures.

Patient Safety and Psychosocial Support

Fall Prevention: Use of side rails, bed alarms for altered sensorium.
Family Education: Communicate patient status and care plan clearly.
Emotional Support: Reassure patient (if conscious) and provide holistic care.

Conclusion

The patient’s clinical course reflects a rapidly progressive and life-threatening condition, likely ascending cholangitis complicated by sepsis, multi-organ dysfunction, and cardiac arrest. Despite the severity of the presentation, the preservation of cardiac function post-arrest and timely identification of biliary obstruction provided a critical opportunity for targeted intervention.

Early recognition, aggressive antibiotic therapy, biliary decompression, and comprehensive supportive care are essential to improving outcomes in such complex cases. This case underscores the importance of prompt multidisciplinary management in patients presenting with signs of systemic infection and biliary obstruction.

Critical management of severe obstructive cholangitis with septic shock in an elderly patient with cardiac and renal comorbidities