A case of worsening jaundice in a critically ill patient

A 58-year-old male was admitted to the hospital with right upper quadrant (RUQ) pain and fever of four days duration. On admission, patient was febrile and hypotensive with RUQ tenderness. Lab work showed leukocytosis, abnormal liver function test (LFTs) (see table) and Escherichia coli bacteremia. His initial imaging showed emphysematous cholecystitis and mildly dilated common bile duct (CBD) and underwent emergent percutaneous cholecystostomy. An ERCP was performed due to concerns of potential concomitant cholangitis which demonstrated a normal intra and extrahepatic biliary system with no filling defects (Fig. 1a) and a plastic biliary stent was placed successfully. Subsequently, the patient underwent open cholecystectomy on the next day and was complicated by intra operative bleeding likely secondary to disseminated intravascular coagulation requiring massive transfusion and continuous use of three vasopressors. Post-operatively, the patient's LFTs increased abruptly suggestive of shock liver and then improved gradually (see table). His hepatitis serologies and immunoglobulin levels were unremarkable. His postoperative course was complicated by dry gangrene involving both the feet and hand and underwent bilateral below knee amputation.