Beyond Charcot’s Triad: Occult Choledocholithiasis Unmasked by Polymicrobial Sepsis and Multifocal Pyogenic Liver Abscesses

Suspected choledocholithiasis/biliary obstruction complicated by ascending cholangitis with pyogenic liver abscesses can rapidly progress to bacteremia, sepsis, and multiorgan dysfunction including distributive shock.Recognition may be delayed when patients lack characteristic diagnostic features, and patients of advanced age or with other comorbidities may present with nonspecific neurologic and metabolic abnormalities that obscure the underlying source.This report describes an atypical case of occult complicated biliary obstruction presenting as refractory polymicrobial sepsis in a 64-year-old woman with type 2 diabetes mellitus and multiple other chronic medical conditions, examining the evolution of clinical findings that ultimately prompted escalation of care including transfer for definitive management.Occult hepatobiliary infection should be considered early in patients with persistent polymicrobial and/or extended-spectrum beta lactamase (ESBL) bacteremia and evolving cholestatic abnormalities, even when Charcot's triad is absent.Early contrast-enhanced imaging and timely biliary decompression, with abscess drainage when indicated, are essential as antimicrobial therapy alone cannot achieve definitive source control.