As with the medical history and physical examination, basic laboratory studies should be performed before progressing to advanced diagnostic testing. Very often, clues from the history and physical examination can guide laboratory testing. Various authors have provided opinions on the initial group of tests that should be performed. These investigators have attempted to determine the diagnostic utility of various laboratory studies in the work-up of an FUO.
A complete blood cell count and a peripheral smear should be performed, since these may provide valuable clues. Atypical lymphocytes suggestive of a viral infection can be identified. A monocytosis may be suggestive of mycobacterial or fungal infection, and eosinophilia may prompt consideration of a parasitic or allergic disease. Rarely, one might observe parasites directly on a peripheral smear. Malaria and Babesia parasites are the most common organisms seen on a peripheral smear. Abnormal hematopoietic cells or their precursors can suggest a hematologic malignancy. Anemia may prompt consideration of myelophthisis or hemolysis. The presence of schistocytes, or torn red blood cells, could suggest microangiopathic or autoimmune hemolysis. Thombocytopenia can also be noted on peripheral smear.
Serum chemistries should also be performed to assess for abnormalities. Liver function test abnormalities are vague diagnostic clues in FUO but can nonetheless be helpful. Abnormalities can prompt earlier assessment of hepatobiliary system. A urinalysis can specifically be useful in determining the presence of genitourinary disease. The erythrocyte sedimentation rate and C-reactive protein, despite their lack of specificity, may be useful in assessing the extent of inflammation. An elevated uric acid level could be a clue to unapparent gout as a cause of the FUO.
Microbiological studies can be used to detect the presence of occult infection. Blood cultures can be very useful in detecting persistent or transient bacteremias caused by endocarditis, occult abscesses, and osteomyelitis. The highest sensitivity is obtained from three sets of blood cultures. Every effort should be made to obtain cultures with the patient off antibiotics. Blood cultures utilizing lysis-centrifugation systems can be used to detect more fastidious organisms such as mycobacteria, endemic mycoses, Bartonella species, and Brucella species. A sputum Gram stain, acid-fast smear for mycobacteria, and routine and mycobacterial cultures can have utility if pulmonary disease is suspected. The tuberculin skin test may prompt consideration of mycobacterial disease. A urine culture can assist in diagnosing infections of the urinary tract and, if positive, may prompt a more thorough search for disease in this region. Finally, stool cultures for bacterial pathogens should be considered when gastrointestinal disease is suspected.
Serologic studies may also be useful in the course of the diagnostic evaluation. Antibody testing for the human immunodeficiency virus may be warranted even if only risk factors are present. In addition, rapid plasma reagent testing should also be performed if syphilis is under consideration.
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Antibiotics and biliary drainage are the mainstays of treatment of acute cholangitis. Other general measures include intravenous fluid hydration and correction of coagulation abnormalities with vitamin К and fresh frozen plasma.
Antibiotic treatment is considered complementary to the establishment of biliary drainage and is used to control sepsis and inflammation.) Conservative management with antibiotics may also help to suitably delay biliary drainage until the acute disease has subsided. Treatment with broad-spectrum antibiotics should be started promptly. The antibiotic regimen can be narrowed once blood culture results become known.
Decompression of the obstructed biliary tree is crucial to the management of acute cholangitis. Surgical exploration and placement of a T-tube can provide definitive therapy of acute cholangitis in patients with difficult ductal stones, but surgery is generally no longer the procedure of choice. Drainage is preferably accomplished with ERCP or a percutaneous transhepatic biliary catheter, since these are both associated with less morbidity and mortality. During percutaneous transhepatic biliary drainage, a catheter is placed into the biliary tree under ultrasonographic or CT guidance, decompressing the biliary tree. ERCP is advantageous because it allows for stone extraction and stent placement during the procedure. After drainage of the biliary ducts, antibiotic treatment is usually continued for 7 to 10 days. A longer course may be recommended for recurrent or refractory disease.
With appropriate therapy, the mortality rate from acute cholangitis is less than 10%. However, it can exceed 50% in patients with acute obstructive suppurative cholangitis.
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BILIARY INFECTIONS: TREATMENT OF ACUTE CHOLANGITISAntibiotics and biliary drainage are the mainstays of treatment of acute cholangitis. Other general measures include intravenous fluid hydration and correction of coagulation abnormalities with vitamin К and fresh frozen plasma.Antibiotic treatment is considered complementary to the establishment of biliary drainage and is used to control sepsis and inflammation.) Conservative management with antibiotics may also help to suitably delay biliary drainage until the acute disease has subsided. Treatment with broad-spectrum antibiotics should be started promptly. The antibiotic regimen can be narrowed once blood culture results become known.Decompression of the obstructed biliary tree is crucial to the management of acute cholangitis. Surgical exploration and placement of a T-tube can provide definitive therapy of acute cholangitis in patients with difficult ductal stones, but surgery is generally no longer the procedure of choice. Drainage is preferably accomplished with ERCP or a percutaneous transhepatic biliary catheter, since these are both associated with less morbidity and mortality. During percutaneous transhepatic biliary drainage, a catheter is placed into the biliary tree under ultrasonographic or CT guidance, decompressing the biliary tree. ERCP is advantageous because it allows for stone extraction and stent placement during the procedure. After drainage of the biliary ducts, antibiotic treatment is usually continued for 7 to 10 days. A longer course may be recommended for recurrent or refractory disease.With appropriate therapy, the mortality rate from acute cholangitis is less than 10%. However, it can exceed 50% in patients with acute obstructive suppurative cholangitis.*108/348/5*
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