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Gallstone pancreatitis with cholangitis — ABIM Board MCQ

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HardGastroenterology/HepatologyGallstone pancreatitis with cholangitisABIM Board

A 67-year-old man is hospitalized with severe epigastric pain radiating to the back. His lipase is 2,400 U/L, total bilirubin is 5.2 mg/dL, and alkaline phosphatase is 340 U/L. Ultrasonography shows gallstones and dilation of the common bile duct. His temperature is 38.8°C (101.8°F). Despite blood cultures, broad-spectrum intravenous antibiotics, crystalloid resuscitation, and initiation of norepinephrine, his blood pressure is 92/56 mm Hg and he remains confused. He has normal upper gastrointestinal anatomy, and therapeutic endoscopy is immediately available. Which of the following is the most appropriate next step in management?

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Correct answer: C — Immediate ERCP with endoscopic biliary decompression

This patient has gallstone pancreatitis complicated by obstructive acute cholangitis and septic shock, indicated by fever, cholestatic laboratory abnormalities, common bile duct dilation, hypotension, and altered mental status. He requires immediate source control with ERCP and biliary decompression in addition to antibiotics and hemodynamic support. Because he remains unstable, rapid stent or nasobiliary drainage may be performed without prolonging the procedure for definitive stone extraction. Percutaneous drainage is an alternative when ERCP is unavailable, unsuccessful, or anatomically impossible. MRCP would delay treatment despite high-risk features that already establish the need for ERCP. Cholecystectomy provides definitive prevention of recurrent gallstone disease but should follow control of cholangitis and clinical stabilization. Antibiotics and vasopressors alone are insufficient without relief of the infected obstruction.

Reference: Buxbaum JL, et al. ASGE guideline on the management of cholangitis. Gastrointestinal Endoscopy. 2021;94:207-221.e14. https://www.asge.org/docs/default-source/default-document-library/piis0016510720351117.pdf