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Severe acute ascending cholangitis — SCE Acute Medicine MCQ

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ModerateGastroenterology and hepatologySevere acute ascending cholangitisSCE Acute Medicine

A 73-year-old woman presents with fever, rigors and right upper quadrant pain. She is jaundiced, confused and hypotensive; bilirubin is 86 micromol/L, ALP is 480 U/L and lactate is 3.8 mmol/L. Ultrasound shows a dilated common bile duct with stones. What is the most appropriate next step in management?

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Correct answer: A — Start broad-spectrum intravenous antibiotics and arrange urgent biliary drainage

Charcot's triad with shock and confusion indicates severe acute cholangitis requiring sepsis treatment and urgent source control by ERCP or drainage. Elective surgery comes after infection and obstruction are controlled. Antibiotics alone are inadequate when there is ongoing biliary obstruction.

Reference: Tokyo Guidelines 2018 acute cholangitis; NICE gallstone disease guidance