Which of the following is the most likely cause of this patient’s condition?
This patient is in septic shock due to ascending cholangitis. Shock is a condition where the body is unable to deliver adequate perfusion to meet metabolic demands. Shock is often characterized by multiorgan dysfunction and hemodynamic changes (i.e. tachycardia, hypotension). Ascending cholangitis is a serious diagnosis that carries high mortality without prompt treatment and recognition. Causes of ascending cholangitis include choledocholithiasis, a biliary tract stricture, or compression by malignant disease. Some cases demonstrate Charcot’s Triad (fever, jaundice, right upper quadrant pain) or Reynolds’ Pentad (Charcot’s triad plus shock and altered mental status). This patient meets all 5 criteria of Reynolds’ Pentad. Rather than a gallstone obstructing the biliary tree, this patient has an underlying malignancy that is obstructing biliary outflow (hinted by weight loss and progressive jaundice over 3 months). Treatment includes antibiotics, IV fluids, and surgical management. The elevated white blood cell count, fever, history, and physical exam support the diagnosis of septic shock. Cardiogenic shock (Choice A) would be more likely in a patient with known baseline cardiac disease, a patient complaining of chest pain or shortness of breath, low ejection fraction seen on echocardiogram, and cold distal extremities. Conditions that can cause cardiogenic shock include STEMI, CHF, and myocarditis. Obstructive shock (Choice B) is seen in conditions, such as pulmonary embolism, tension pneumothorax, or cardiac tamponade. The patient’s history and physical do not support this diagnosis. Hypovolemic shock (Choice D) can be caused by severe dehydration or hemorrhagic shock (a type of hypovolemic shock). This patient likely has some component of dehydration, but septic shock is the primary condition in this patient. Septic shock is a form of Distributive shock (Choice C). Anaphylactic shock also is a type of Distributive shock. Correct Answer: C
Nicks BA, Gaillard JP. Approach to Nontraumatic Shock. “Chapter 12: Approach to Nontraumatic Shock”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.
Donaldson, R. (2020, May 2). Ascending cholangitis. WikEm. https://www.wikem.org/wiki/Ascending_cholangitis