DD in elderly patient

Case: 82 years old female who, earlier in the day, went through Endoscopic retrograde cholangiopancreatography (ERCP) is transferred from the floor (ward) with hypotension. Patient has chronic steroid-dependent Chronic obstructive pulmonary disease (COPD). Labs are pending, but as the other four components of 'Reynolds pentad' are absent on clinical exam, suppurative cholangitis can be safely ruled out by differential diagnosis? 

A) True

B) False

Answer; B

This question aims to highlight that clinical exams can be highly deceiving in elderly patients and those patients who are on steroid treatment. 

In view of this patient's early history of undergoing ERCP, severe (suppurative) cholangitis cannot be ruled out just by the absence of Reynolds pentad, i.e., fever, abdominal pain, jaundice, and hypotension. Patterns of obstructive enzymes on the Liver Function Test (LFT) and imagings are required to establish the diagnosis.

Proper diagnosis is imperative as  AOSC (acute obstructive suppurative cholangitis) in the elderly can quickly become fatal.

#hepatology

References:

1. Arima N, Uchiya T, Hishikawa R, Saito M, Matsuo T, Kurisu S, Umeki M, Kita Y, Koyama T, Hatta T, et al. [Clinical characteristics of impacted bile duct stone in the elderly]. Nihon Ronen Igakkai Zasshi. 1993 Nov;30(11):964-8. Japanese. doi: 10.3143/geriatrics.30.964. PMID: 8295355.

2. Skinner TR, Scott IA, Martin JH. Diagnostic errors in older patients: a systematic review of incidence and potential causes in seven prevalent diseases. Int J Gen Med. 2016 May 20;9:137-46. doi: 10.2147/IJGM.S96741. PMID: 27284262; PMCID: PMC4881921.