Acute gallstone cholangitis with circulatory compromise — MRCEM SBA MCQ

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EasyInfection and sepsisAcute gallstone cholangitis with circulatory compromiseMRCEM SBA

A 67-year-old woman attends the emergency department with fever, jaundice and right upper quadrant pain. Her blood pressure remains 82/48 mmHg after initial intravenous fluid resuscitation, and venous lactate is 4.2 mmol/L. Ultrasound shows a dilated common bile duct with an obstructing distal duct stone. Blood cultures have been taken, intravenous antibiotics have started, and critical care review is under way. Which intervention should be arranged urgently alongside continued resuscitation?

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Correct answer: A — ERCP with biliary drainage

The fever, jaundice and right upper quadrant pain indicate acute cholangitis; ultrasound identifies an obstructing common bile duct stone. Persistent hypotension and raised lactate make urgent source control particularly important. **ERCP with biliary drainage** addresses the infected obstruction while resuscitation, intravenous antibiotics and critical care assessment continue. UK specialty guidance recommends urgent biliary decompression for acute cholangitis with signs of septic shock, using endoscopic stone extraction or biliary stenting where appropriate. ([gut.bmj.com](https://gut.bmj.com/content/early/2017/01/25/gutjnl-2016-312317?versioned=true&utm_source=openai)) **B** is attractive when a duct stone is suspected but unconfirmed. Here ultrasound has already demonstrated the obstruction, so MRCP would delay drainage. **C** may be needed later to prevent further gallstone disease, but removing the gallbladder is not the immediate means of draining this obstructed duct. **D** can seem reasonable in milder cholangitis that responds to treatment; persistent circulatory compromise makes a trial of antibiotics without urgent drainage inappropriate. **E** drains the gallbladder and can be useful for selected patients with acute cholecystitis, but it does not reliably relieve this common bile duct obstruction. If ERCP cannot be performed, percutaneous *biliary* drainage—not cholecystostomy—is an alternative. ([gut.bmj.com](https://gut.bmj.com/content/early/2017/01/25/gutjnl-2016-312317?versioned=true&utm_source=openai))

Reference: Updated guideline on the management of common bile duct stones (2017) — https://gut.bmj.com/content/early/2017/01/25/gutjnl-2016-312317?versioned=true UHB Antimicrobial Guidelines: Acute Cholangitis/Cholecystitis (Version reviewed June 2026; section reviewed July 2024) — https://www.uhb.nhs.uk/media/513l1wph/antimicrobialprescribingguidelines.pdf