What is the most likely diagnosis and appropriate management for a hypertensive adult who, three days after cholecystectomy, presents with fever, chills, abdominal pain, vomiting, icterus, slurred speech, and hypotension?

Post-Cholecystectomy Septic Shock Secondary to Bile Duct Injury with Cholangitis

This patient has severe (Grade III) acute cholangitis with septic shock secondary to a major bile duct injury, requiring immediate broad-spectrum antibiotics within 1 hour, urgent biliary drainage (percutaneous transhepatic or endoscopic), aggressive resuscitation, and referral to a hepatopancreatobiliary center for definitive surgical repair. 1, 2

Diagnosis

The clinical presentation confirms severe acute cholangitis with septic shock complicating a major bile duct injury (likely Strasberg E1-E2):

• Charcot's triad is present: fever/chills, abdominal pain, and jaundice (icterus), which establishes the diagnosis of acute cholangitis 3
• Reynolds' pentad is complete with the addition of altered mental status (slurred speech) and hypotension (90/60 mmHg), indicating severe septic cholangitis 4, 3
• The post-cholecystectomy timing (3 days) with failure to recover normally triggers mandatory investigation per 2020 WSES guidelines 1, 2
• Hypotension (BP 90/60) with fever and altered mental status defines severe (Grade III) cholangitis with organ dysfunction requiring urgent intervention 3

The slurred speech represents septic encephalopathy from severe systemic infection, not a primary neurological event, and should resolve with source control 3.

Immediate Management Algorithm

Step 1: Resuscitation and Antibiotics (Within 1 Hour)

• Start broad-spectrum antibiotics within 1 hour of presentation—this is non-negotiable in severe sepsis/shock 1
• Recommended regimens: piperacillin-tazobactam, imipenem-cilastatin, or meropenem 1
• Add amikacin in the setting of shock for enhanced gram-negative coverage 1
• Add fluconazole given the delayed presentation (3 days post-op suggests fragility) 1
• Aggressive fluid resuscitation with crystalloids to restore perfusion 3
• Obtain blood cultures and inflammatory markers (CRP, procalcitonin, lactate) before antibiotics but do not delay treatment 1

Step 2: Diagnostic Imaging (Within 6 Hours)

• Abdominal triphasic CT is the first-line imaging to detect fluid collections, biloma, and ductal dilation 1, 2
• Contrast-enhanced MRCP should follow to precisely localize and classify the bile duct injury, which is essential for surgical planning 1, 2
• In severe sepsis/shock, the investigation window must be shortened—imaging should not delay biliary drainage if the diagnosis is clinically certain 1

Step 3: Urgent Biliary Drainage (Within 24 Hours)

• Percutaneous transhepatic biliary drainage (PTBD) is the preferred initial drainage method in septic patients with complete bile duct obstruction, as it provides immediate decompression with minimal morbidity (7% complication rate, no mortality in stable patients) 5, 6
• Sepsis begins to resolve within 24 hours of successful drainage in all patients 5
• Alternative: ERCP with sphincterotomy and stent placement if the anatomy permits and the patient can tolerate endoscopy 1
• Do not attempt definitive cholangiography during initial drainage—inject only 1-2 mL of contrast to confirm catheter placement 5

Step 4: Definitive Surgical Planning

For major bile duct injuries (Strasberg E1-E2) diagnosed within 72 hours:

• Immediate referral to a hepatopancreatobiliary (HPB) center for urgent surgical repair with Roux-en-Y hepaticojejunostomy 2
• However, given this patient's septic shock, a staged approach is safer: 2
  • Continue percutaneous drainage
  • Broad-spectrum antibiotics tailored to bile cultures
  • Nutritional support
  • Wait at least 3 weeks for acute inflammation to resolve
  • Then perform definitive Roux-en-Y hepaticojejunostomy 2

If diffuse biliary peritonitis is found on imaging:

• Immediate abdominal lavage and drainage are required for source control before any definitive repair 2

Antibiotic Duration

• Continue antibiotics for 4 additional days after successful biliary drainage per Tokyo Guidelines 1
• Extend to 2 weeks if Enterococcus or Streptococcus are isolated on bile cultures to prevent infectious endocarditis 1
• For biloma or generalized peritonitis, treat for 5-7 days 1
• Adjust therapy based on bile and blood culture results 1

Critical Pitfalls to Avoid

• Never delay antibiotics beyond 1 hour in severe sepsis/shock—the investigation window must be substantially shortened 1
• Never dismiss post-cholecystectomy symptoms as "normal recovery"—undiagnosed bile duct injury can progress to secondary biliary cirrhosis, portal hypertension, liver failure, and death 2, 7
• Do not attempt immediate definitive repair in a septic patient—staged management after drainage and sepsis resolution has lower morbidity and mortality 2
• Do not rely on ultrasound alone—CT abdomen is superior for detecting bile duct stones and collections in post-cholecystectomy patients with sepsis 6

Prognosis

• With prompt biliary drainage, sepsis resolves within 24 hours in all patients 5
• Mortality in severe cholangitis with shock is 5% even with optimal management 5
• Definitive surgical repair after staged management has 18% morbidity and 0% mortality, compared to higher rates with emergency surgery 5