This is a 76-year-old woman who was admitted to the vascular surgery department for postphlebitic syndrome. During her stay on the ward she showed clinical deterioration and was transferred to the ICU on 10/5/03 with severe sepsis.
His past history of interest included high blood pressure, obesity, arthrosis and resection of a tubular adenoma of the colon. In August 2000 he underwent cholecystectomy for lithiasic cholecystitis with significant subhepatic inflammatory plastron that required subtotal resection of the gallbladder. On admission, he developed DVT of IBD with subsequent PTE and atrial fibrillation, starting treatment with amiodarone and dicoumarin. During the last month he was in outpatient care due to non-specific digestive symptoms, with elevated GGT and AF observed in analytical control.
On examination in the ICU she was stuporous, icteric and with arterial hypotension. O2 saturation was preserved with a mask. Cardiac auscultation rhythmic at 80 bpm, without murmurs. Pulmonary auscultation was normal. The abdomen was globular, painful on palpation in the right hemiabdomen, although without signs of peritoneal irritation and the IBD showed good evolution of its thrombosis.
Laboratory tests showed leukocytosis (37,000/mm3) with neutrophilia, urea 1.83 g/l, creatinine 4.2 mg/dl total bilirubin 8.6 mg/dl, with a direct fraction of 5.7 mg/dl, AST 312 U/l, ALT 106 U/l, GGT 416 U/l. With the diagnosis of sepsis of biliary origin, treatment was started with fluid therapy, dopamine and empirical antibiotics with piperacillin/tazobactam, obtaining a good initial response.
Complementary tests performed: CT scan of the abdomen (11/5/03) showing multiple hypodense images in the hepatic parenchyma suggesting abscesses. Transthoracic and transesophageal echocardiogram, which confirmed the existence of endocarditis at the mitral subvalvular level leading to grade II insufficiency. Following this finding, vancomycin and gentamicin were added to the antibiotic treatment. FNA of a liver lesion. ERCP did not show dilatation of the biliary tract, although papillotomy was performed to ensure biliary drainage. Subsequent evolution was unfavourable with the establishment of refractory BMDS and exitus 96 hours after admission to the ICU.
We requested a necropsy, which revealed multicentric cholangiocarcinoma, with multiple nodules throughout the organ, local extension to the gallbladder bed and extrahepatic bile ducts, regional metastases to lymph nodes in the hepatic hilum and distant metastases, manifested by microscopic foci in the lung.

There was also extensive intratumoral necrosis with superinfection by Enterobacter cloacae, also isolated in blood and FNA sample, which leads us to suppose that it was the germ responsible for the septic picture.