What is the appropriate management for a 5-year-old patient with a 15-day history of fever, 3-day history of jaundice (yellow discoloration of urine), and 2-day history of abdominal distention?

Management of a 5-Year-Old with Prolonged Fever, Jaundice, and Abdominal Distention

This child requires urgent hospitalization with immediate broad-spectrum parenteral antibiotics, blood and urine cultures, abdominal ultrasound, and preparation for possible biliary drainage, as the combination of prolonged fever (15 days), jaundice (3 days), and abdominal distention (2 days) strongly suggests cholangitis with possible biloma, abscess, or biliary peritonitis.

Immediate Life-Threatening Assessment

Critical Red Flags Present

• Fever with jaundice and abdominal distention constitutes a surgical emergency requiring immediate evaluation for cholangitis, biliary obstruction, or intra-abdominal sepsis 1
• Assess for signs of septic shock (hypotension, altered mental status, poor perfusion) as sepsis accounts for 22% of new-onset jaundice cases and requires intervention within 1 hour 2, 1
• Evaluate for coagulopathy (INR >1.5) and encephalopathy, which indicate fulminant hepatic failure requiring immediate hepatology consultation 2, 3
• The combination of fever, jaundice, and abdominal pain/distention suggests Charcot's triad, indicating acute cholangitis requiring urgent biliary decompression 1, 2, 3

Immediate Diagnostic Workup

Laboratory Studies (Stat)

• Obtain blood cultures, urine cultures, complete blood count, and coagulation studies immediately before starting antibiotics 1, 2, 3
• Measure total and fractionated bilirubin, AST, ALT, alkaline phosphatase, GGT, and albumin to distinguish hepatocellular from cholestatic patterns 1, 2, 3
• Add CRP, procalcitonin, and lactate levels to assess severity of acute inflammation and sepsis 1
• A cholestatic pattern (predominant alkaline phosphatase/GGT elevation with modest transaminase elevation) suggests biliary obstruction 2

Imaging Strategy

• Perform abdominal ultrasound immediately as the first-line imaging modality to detect biliary ductal dilation, intra-abdominal fluid collections (biloma), abscesses, or pyonephrosis 1, 2
• Ultrasound has 32-100% sensitivity and 71-97% specificity for detecting biliary obstruction with no radiation exposure, making it ideal for pediatric patients 2, 3
• If ultrasound shows biliary obstruction or fluid collections but anatomy is unclear, proceed urgently to contrast-enhanced MRCP for exact visualization and localization 1
• Abdominal distention in this context may represent biloma, abscess, or biliary peritonitis, all requiring imaging-guided intervention 1

Immediate Management

Antibiotic Therapy

• Start parenteral broad-spectrum antibiotics immediately (within 1 hour if sepsis suspected, within 6 hours for less severe presentations) 1
• Appropriate regimens include piperacillin/tazobactam, meropenem, or ertapenem; add amikacin if shock is present and fluconazole if delayed diagnosis or patient appears fragile 1
• For a 5-year-old child, if urinary tract infection is contributing (given yellow urine), use parenteral cephalosporin (ceftriaxone 50-75 mg/kg/day or cefotaxime 150 mg/kg/day in divided doses) until clinical improvement 1
• Adapt antibiotics based on blood and bile culture results once available 1

Biliary Drainage Considerations

• If cholangitis is confirmed (fever + jaundice + biliary obstruction on imaging), urgent biliary decompression is required 1
• The Tokyo Guidelines stratify severity: Grade 3 (severe) requires urgent decompression, Grade 2 (moderate) requires early decompression within 24 hours, and Grade 1 (mild) can be initially observed on medical treatment 1
• Early biliary drainage (within 24 hours) significantly reduces 30-day mortality in moderate acute cholangitis 1
• Percutaneous transhepatic biliary drainage (PTBD) should be placed for uncontrolled or recurrent cholangitis 1

Management of Complications

• If biloma is detected on ultrasound, percutaneous drainage is required 1
• If biliary peritonitis is present (diffuse peritonitis on examination), surgical consultation for operative drainage is necessary 1
• Multiple small cholangiolytic abscesses may respond to parenteral antibiotics and biliary drainage alone 1
• A large abscess not responding to antibiotics within 48-72 hours requires US- or CT-guided percutaneous drainage 1

Duration of Antibiotic Therapy

• Continue antibiotics for 4 additional days after successful biliary decompression for cholangitis 1
• If Enterococcus or Streptococcus is isolated, treat for 2 weeks to prevent infectious endocarditis 1
• For biloma or generalized peritonitis, treat for 5-7 days 1

Pediatric-Specific Considerations

Urinary Tract Infection Evaluation

• Given the yellow discoloration of urine in a 5-year-old with prolonged fever, obtain urinalysis and urine culture via catheterization or suprapubic aspiration (not bag specimen) 1
• Urinary tract infection prevalence in febrile children aged 2-5 years without obvious source is 3-7%, and can coexist with other infections 1
• If UTI is confirmed, perform renal and bladder ultrasound during the first 2 days if clinical illness is severe or improvement is inadequate 1

Alternative Diagnoses to Consider

• Viral hepatitis (hepatitis A, B, C, EBV, CMV) can cause prolonged fever and jaundice but typically lacks abdominal distention unless complicated by ascites 2, 4
• Drug-induced liver injury from medications or herbal supplements should be assessed through detailed exposure history 2, 3
• Hemolytic processes causing unconjugated hyperbilirubinemia would not explain the abdominal distention or prolonged fever pattern 2, 5

Critical Pitfalls to Avoid

• Do not delay antibiotics or imaging while awaiting subspecialty consultation—this child requires immediate intervention 1
• Do not assume viral illness based on age alone; bacterial cholangitis and biliary complications occur in children and carry significant morbidity 1
• Do not rely on oral antibiotics for initial management; parenteral therapy is mandatory until clinical improvement is demonstrated 1
• Do not discharge home without imaging and culture results given the severity and duration of symptoms 1, 2
• Yellow urine alone does not exclude biliary pathology; it may represent both conjugated hyperbilirubinemia and concurrent UTI 1, 2