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Ascending cholangitis — MCCQE Part 1 MCQ

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HardJaundiceAscending cholangitisMCCQE Part 1

70-year-old man presents with fever, jaundice and right upper-quadrant pain. He is confused and hypotensive; bilirubin and alkaline phosphatase are elevated. Which of the following is the most appropriate next step?

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Correct answer: B — Give broad-spectrum antibiotics and urgent biliary drainage with ERCP

Give broad-spectrum antibiotics and urgent biliary drainage with ERCP is best because Charcot triad plus hypotension/confusion indicates severe ascending cholangitis. Discharge with reassurance and routine follow-up only is suboptimal because it underestimates acute or progressive risk; Treat symptomatically and defer definitive assessment is suboptimal because symptom control alone does not address the likely underlying diagnosis; Arrange non-urgent outpatient imaging in several months is suboptimal because delayed imaging is unsafe when the presentation has red flags; Start long-term corticosteroids without confirming the diagnosis is suboptimal because empiric steroids can obscure infection, malignancy or other diagnoses. Source control is as important as antibiotics in cholangitis.

Reference: Canadian Association of Gastroenterology biliary guidance