A 58-year-old man was transferred to Peking Union Medical College Hospital for management of newly diagnosed cholangitis.
Six months before admission, the patient began to have episodes of epigastric pain after meal, without nausea, vomiting or diarrhea, the pain could be relieved after rest. Three months previously, he was hospitalized in the local emergency department because of the aggravation of postprandial epigastric pain and fever. The highest body temperature could reach 38.7 C. Choledocholithiasis was diagnosed by abdominal CT in local hospital. He was treated with fluid replacement and antibiotic therapy for a week until symptoms relief. One week before admission, severe epigastric pain with fever and chills occurred, and the highest body temperature could reach 39.0 C. The patient had anorexia and fatigue, but did not lose weight through the course of the disease. Treated with antipyretic and antibiotic medication, he was transferred to Peking Union Medical College Hospital for further treatment.
The patient underwent exploratory laparotomy for hemostasis 30 years ago because of a traffic accident. Abdominal incisional hernia was developed after laparotomy and detailed medical records of that operation were not available. He did not have hypertension, coronary heart disease, viral hepatitis or exposure to tuberculosis (timeline of the patient medical records is demonstrated in the Table 1).
On physical examination, the temperature was 36.0 C, the heart rate 73 beats per minute, the respiratory rate 17 breaths per minute, the blood pressure 109/67mmHg and the oxygen saturation 99 percent while the patient breathing ambient air. No significant yellowing was found in the skin or mucous membrane of the patient. His abdomen was flat and longitudinal old surgical scar and drainage tube scar could be seen. The abdominal wall herniation could be found on the left side of the incisional scar and the hernia sac was flexible and painless. Superficial lymph nodes of the patient could not be touched. The upper abdominal tenderness and rebound pain were positive, with negative Murphy's sign and negative shifting dullness. Liver and spleen could not be reached under the rib. The remainder of the examination was normal.
On the day 1 of admission, laboratory test indicated sodium 132 mmol/L, potassium 4.8 mmol/L, chloride 94 mmol/L, calcium 2.48 mmol/L, carbon dioxide 23.7 mmol/L, urea 3.39 mmol/L, creatinine 65 micromoI/L, albumin 43 g/L, direct bilirubin 6.6 mmol/L, total bilirubin 9.8 mmol/L, serum alanine aminotransferase 102 U/L, hemoglobin 129 g/L, white cells 9,410 per mm3, platelets 558,000 per mm3, alpha fetoprotein 4.9 ng/ml, carcinoembryonic antigen 3.8 ng/ml, carbohydrate antigen 19-9 426.6 U/ml.