What is the best course of action for a patient in their early 60s, with a history of sepsis, possible severe colitis, acute cholecystitis, and recent development of jaundice and deranged liver function after undergoing anterior resection and cholecystectomy, and receiving 2 packs of red blood cells (RBCs), with a background of acute renal failure requiring haemodialysis?

Progressive Jaundice and Deranged Liver Function Post-Cholecystectomy in ICU Patient

This patient requires urgent investigation for bile duct injury (BDI) with immediate imaging (triphasic CT followed by MRCP), broad-spectrum antibiotics, and hepatobiliary surgical consultation, as progressive jaundice on day 8 post-cholecystectomy strongly suggests a major bile duct injury or biliary leak with evolving sepsis. 1

Immediate Diagnostic Workup

Clinical Assessment

• Evaluate for alarm symptoms including fever, abdominal pain, distention, worsening jaundice, nausea, and vomiting—all indicators of potential BDI 1
• Assess for signs of biliary sepsis including hemodynamic instability, worsening inflammatory markers, and organ dysfunction 1
• Consider transfusion-related hemolysis given recent RBC transfusion, though the progressive nature and timing make this less likely 2

Laboratory Investigations

• Obtain comprehensive liver function tests including direct and indirect bilirubin, AST, ALT, alkaline phosphatase, GGT, and albumin 1, 3
• Monitor inflammatory markers including CRP, procalcitonin, and lactate to assess severity of acute inflammation and sepsis 1
• Check haptoglobin, reticulocyte count, LDH, and Coombs test to exclude hemolysis from transfusion 2
• Obtain coagulation profile to assess hepatic synthetic function 2

Imaging Strategy

• Perform triphasic CT scan immediately as first-line imaging to detect intra-abdominal fluid collections (bilomas), ductal dilation, and assess for complications 1
• Follow with contrast-enhanced MRCP to obtain exact visualization, localization, and classification of BDI, which is essential for planning tailored treatment 1, 3
• Abdominal ultrasound with Doppler can supplement if MRCP is delayed, though less definitive 3

Immediate Medical Management

Antibiotic Therapy

• Initiate broad-spectrum antibiotics within 1 hour given the high likelihood of biliary sepsis in this critically ill patient 1, 4
• Use piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem as these cover gram-negative aerobes, enterococci, and anaerobes causing biliary infections 1, 4
• Add fluconazole in this fragile patient with delayed diagnosis and multiple risk factors for fungal infection 1
• Adjust antibiotics according to bile culture results if drainage procedures are performed 1

Supportive Care

• Continue hemodialysis as indicated for acute renal failure management 1
• Optimize fluid balance using continuous renal replacement therapy given hemodynamic instability in septic patients 1
• Maintain glucose control with target blood glucose ≤180 mg/dL using protocolized insulin therapy 1
• Provide VTE prophylaxis with unfractionated heparin given creatinine clearance <30 mL/min on dialysis 1

Differential Diagnosis and Management Strategy

Major Bile Duct Injury (Most Likely)

• Strasberg E1-E2 injuries present with progressive jaundice, biliary leak, and sepsis in the early postoperative period 1
• Immediate HPB surgical consultation is mandatory for major BDIs diagnosed within 8 days post-operatively 1
• Percutaneous drainage of fluid collections should be performed urgently if bilomas are present 1
• ERCP with sphincterotomy and stent placement may reduce pressure gradient in the biliary tree and facilitate drainage 1
• Definitive surgical repair with Roux-en-Y hepaticojejunostomy should be delayed until after 3 weeks if patient stabilizes, allowing resolution of acute inflammation 1

Biliary Leak with Biloma/Bile Peritonitis

• Source control is the first priority with percutaneous or surgical drainage 1, 2
• Broad-spectrum antibiotics started immediately as outlined above 1
• ERCP with biliary sphincterotomy and stent placement becomes mandatory if no improvement occurs with drainage alone 1

Acalculous Cholecystitis (Less Likely Post-Cholecystectomy)

• This patient already underwent cholecystectomy, making this diagnosis unlikely 5, 6

Sepsis-Induced Cholestasis

• Inflammation-induced alterations in bile acid transport occur early in critical illness and can cause cholestatic patterns 7
• However, progressive worsening on day 8 post-operatively strongly favors mechanical/surgical etiology over pure septic cholestasis 1, 7

Transfusion-Related Hemolysis

• Recent 2-unit RBC transfusion could contribute to unconjugated hyperbilirubinemia 2
• Check haptoglobin, reticulocyte count, LDH, and Coombs test to assess this contribution 2
• Unlikely to be sole cause given progressive nature and deranged liver function tests 2

Critical Pitfalls to Avoid

• Do not delay imaging waiting for laboratory results—progressive jaundice post-cholecystectomy requires urgent CT/MRCP 1
• Do not attempt immediate surgical repair of complex injuries in this critically ill, septic patient with renal failure—stabilization and delayed repair after ≥3 weeks yields better outcomes 1
• Do not withhold antibiotics pending culture results—biliary sepsis requires empiric broad-spectrum coverage within 1 hour 1, 4
• Do not overlook percutaneous drainage of fluid collections—source control is essential before definitive surgical repair 1
• Do not assume septic cholestasis alone—mechanical obstruction or bile leak must be excluded with imaging in post-cholecystectomy patients 1, 2

Multidisciplinary Approach Required

• Hepatobiliary surgery consultation immediately for suspected major BDI 1
• Interventional radiology for percutaneous drainage of bilomas if present 1
• Gastroenterology/ERCP team for endoscopic management of bile leaks or obstruction 1
• Critical care team for ongoing sepsis management, renal replacement therapy, and hemodynamic support 1
• Infectious disease consultation may be warranted given complex septic picture with multiple organ failure 1