Sandbox

Management

Characterize the symptoms: ❑ RUQ abdominal pain ❑ Intermittent fever &/or chills ❑ Jaundice ❑ Lethargy or confusion

Examine the patient: ❑ Altered mental status ❑ Febrile ❑ Dehydrated ❑ Jaundice ❑ Hypotension ❑ Tachycardia ❑ Dyspnea ❑ Hypoxemia ❑ Abdominal tenderness

Order laboratory tests: ❑ CBC ❑ BMP ❑ CRP ❑ Total bilirubin ❑ Direct bilirubin ❑ Albumin ❑ AST ❑ ALT ❑ Alkaline phosphatase ❑ GGT ❑ Amylase ❑ Lipase

Diagnostic criteria: ❑ Systemic inflammation ❑ Fever >38℃ and/or shaking chills ❑ WBC (×1000/μl) <4, or >10 ❑ CRP (mg/dl) ≥1 ❑ Cholestasis ❑ Jaundice with total bilirubin ≥2 (g/dl) ❑ ALP (IU) >1.5×STD ❑ GGT (IU) >1.5×STD ❑ AST (IU) >1.5×STD ❑ ALT (IU) >1.5×STD ❑ Imaging ❑ Biliary dilatation ❑ Evidence of etiology (stricture, stone, stent etc.)

❑ Hospital admission ❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ Blood C&S ❑ Empiric IV antibiotics ❑ Ceftriaxone 1 g IV every 24 hours + Metronidazole 500 mg IV every 8 hours or ❑ Ciprofloxacin 400 mg IV every 12 hours/Levofloxacin 500 or 750 mg IV once daily + Metronidazole 500 mg IV every 8 hours ❑ Acute pain management ❑ Ketorolac 30-60 mg IM/IV single dose or ❑ Opioids until drainage or surgical intervention if ketorolac is contraindicated/pain not improving ❑ Assess severity

Grade 1 (Mild)

Grade 2 (Moderate)

Grade 3 (Severe)

❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ IV antibiotics (full dose) ❑ IV pain management w/ analgesics ❑ Assess severity ❑ Within 24 hours after diagnosis (every 6-12 hours) ❑ During the time zone of 24-48 hours (every 6-12 hours)

❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ IV antibiotics (full dose) ❑ IV pain management w/ analgesics ❑ Assess severity ❑ Within 24 hours after diagnosis (every 6-12 hours) ❑ During the time zone of 24-48 hours (every 6-12 hours) ❑ Immediate biliary tract drainage within 24-48 hours

❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ IV antibiotics (full dose) ❑ IV pain management w/ analgesics ❑ Assess severity ❑ Within 24 hours after diagnosis (every 6-12 hours) ❑ During the time zone of 24-48 hours (every 6-12 hours) ❑ Immediate organ support ❑ NIPPV/ IPPV ❑ Vasopressors ❑ Urgent biliary tract drainage

Improvement

No improvement within the first 24 hours

Finish antibiotic course

Immediate biliary tract drainage within 24 hours

Treatment for etiology if still needed (endoscopic treatment, percutaneous treatment, or operative intervention)