Differential Diagnosis

The patient presents with right upper quadrant pain, nausea, fever, vomiting, and elevated bilirubin and ALP levels after a recent CBD stent insertion. The CT scan findings and clinical presentation guide the differential diagnosis.

• Single Most Likely Diagnosis

  • Cholangitis: The patient's symptoms of right upper quadrant pain, fever, and vomiting, combined with the elevated CRP and bilirubin levels, are highly suggestive of cholangitis. The recent CBD stent insertion is a risk factor for this condition. The presence of pneumobilia and fat stranding around the gallbladder on the CT scan further supports this diagnosis.

• Other Likely Diagnoses

  • Stent Occlusion or Malfunction: Given the recent stent placement and the patient's symptoms, stent occlusion or malfunction is a possible cause. The CT scan shows moderate dilation of the perihilar intrahepatic bile ducts, which could indicate inadequate drainage.
  • Post-ERCP Pancreatitis: Although the patient underwent stent insertion and not a typical ERCP, the procedure can still cause pancreatitis. However, the normal ALT level and the absence of specific findings suggestive of pancreatitis on the CT scan make this less likely.
  • Hepatic Abscess: The CT scan mentions small locules within the liver hilum, which could potentially represent hepatic abscesses. However, the absence of definitive findings and the clinical context make cholangitis more likely.

• Do Not Miss Diagnoses

  • Perforation of the Biliary Tree: Although the CT scan does not show free intraperitoneal air, the possibility of a contained perforation, especially given the pneumobilia and the patient's symptoms, must be considered. This is a serious condition that requires prompt intervention.
  • Sepsis: The patient's fever, elevated CRP, and WCC, although not markedly elevated, necessitate consideration of sepsis, particularly in the context of a possible infection like cholangitis.

• Rare Diagnoses

  • Hemobilia: This condition, characterized by bleeding into the biliary tree, could potentially cause the patient's symptoms. However, there's no specific evidence on the CT scan or in the lab results to strongly support this diagnosis.
  • Biliary Tree Injury: An injury to the biliary tree during the stent insertion procedure is a rare but possible complication. The presence of pneumobilia could be indicative of such an injury, but the clinical context and CT findings do not strongly support this as the primary diagnosis.

Management

The management of this patient should be focused on the most likely diagnosis, cholangitis, while also considering the other possibilities. This includes:

• Antibiotics: Broad-spectrum antibiotics should be continued or adjusted based on culture results to cover for common biliary pathogens.
• Stent Patency: Ensure the CBD stent is patent and functioning correctly. Consider a repeat ERCP or other interventions if necessary.
• Supportive Care: Manage symptoms such as pain, nausea, and vomiting with appropriate medications.
• Monitoring: Close monitoring of the patient's condition, including laboratory parameters and clinical symptoms, is essential. Repeat imaging may be necessary if there's no improvement or if the patient's condition worsens.
• Consideration for Interventional Procedures: Depending on the patient's response to initial management, further procedures such as stent revision or drainage of potential abscesses may be required.