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Acute cholangitis — ESEGH MCQ

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HardPancreatico-biliary DiseaseAcute cholangitisESEGH

A 73-year-old man presents with fever, rigors, right upper quadrant pain and confusion. Blood pressure is 86/48 mmHg. Blood tests show bilirubin 116 micromol/L, ALP 540 IU/L, ALT 168 IU/L and lactate 4.1 mmol/L. Ultrasound shows a dilated common bile duct with gallstones. What is the most appropriate management?

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Correct answer: E — Immediate sepsis resuscitation, antibiotics and urgent biliary drainage

This is severe acute cholangitis with septic shock, requiring resuscitation, broad-spectrum antibiotics and urgent biliary drainage, usually by ERCP. Elective management is unsafe in shock. Ursodeoxycholic acid does not drain an infected obstructed biliary tree. The pearl is that source control is the definitive treatment in obstructive cholangitis.

Reference: Tokyo Guidelines for Acute Cholangitis; BSG ERCP Guidance