Acute cholangitis
USMLE Step 2 CKDifficulty: mediumLast updated:
A 72-year-old woman presents with 2 days of right upper quadrant pain, fever with rigors, and yellowing of the eyes. Temperature is 39.2°C (102.6°F), pulse 108/min, and blood pressure 112/70 mm Hg after 1 L of IV crystalloid. She is alert and oriented. Total bilirubin is 4.8 mg/dL, alkaline phosphatase 410 U/L, and leukocyte count 17,500/mm3. Ultrasound shows gallstones, a common bile duct dilated to 11 mm, and an echogenic focus with shadowing in the distal common bile duct. Blood cultures are drawn and IV piperacillin-tazobactam is started.
Which of the following is the most appropriate next step in management?
Answer and explanation
Correct answer: D. Endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction
Fever, right upper quadrant pain, and jaundice (Charcot triad) with a dilated common bile duct and a visible distal stone indicate acute cholangitis from choledocholithiasis. The source notes that Charcot triad is about 90% specific for cholangitis, and that confusion and hypotension added to it form Reynolds pentad. It states that early endoscopic or surgical decompression is indicated. When biliary obstruction is suspected, ERCP with sphincterotomy is needed to remove the stones. Antibiotics similar to those for acute cholecystitis are given, such as piperacillin/tazobactam, a third-generation cephalosporin, or meropenem, guided by blood cultures. Antibiotics alone do not relieve the obstruction. Cholecystectomy is usually done later to prevent recurrence, but it does not decompress an obstructed common bile duct.
Each option explained
- A. Hepatobiliary iminodiacetic acid (HIDA) scanIncorrect. A HIDA scan evaluates cystic duct obstruction (acute cholecystitis); the diagnosis here is already clear.
- B. Continue IV antibiotics alone and discharge when afebrileIncorrect. Antibiotics without drainage leave the infected, obstructed biliary system untreated.
- C. Percutaneous cholecystostomyIncorrect. Cholecystostomy drains the gallbladder (used in acute cholecystitis), not an obstructed common bile duct.
- D. Endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extractionCorrect. Cholangitis from a common bile duct stone requires biliary decompression, typically ERCP with sphincterotomy and stone removal.
- E. Emergency laparoscopic cholecystectomyIncorrect. Cholecystectomy does not clear an obstructed common bile duct and is usually done after the duct has been decompressed.
Key point
Acute cholangitis (Charcot triad) needs antibiotics plus early biliary decompression, usually ERCP with sphincterotomy.
From the source
“If biliary obstruction is suspected, ERCP and sphincterotomy are necessary to remove the stones.”