HEPATOBILIARY & PANCREAS • SENIOR RESIDENT / SURGEON

Acute Cholangitis

Biliary infection becomes an emergency when obstruction and sepsis coexist; the learner must recognize that antibiotics alone are not source control.

PROTOTYPE REVIEW REQUIRED

The Call

72-year-old patient with fever, jaundice and right upper quadrant pain

The patient is tachycardic and hypotensive with leukocytosis, hyperbilirubinemia and cholestatic liver-test elevation. Ultrasound shows biliary dilation and probable common duct obstruction.

T 39.2 C • HR 124 • BP 88/54

This is not simply gallstone disease; infected obstruction requires resuscitation plus biliary decompression.

Read the Image • Clinical Data

Biliary Imaging Use ductal imaging from the ACS archive when available to show obstruction and biliary dilation. Clinical image slot reserved for this case.

Make the Decision • Commit to a Plan

A patient with fever, jaundice, hypotension and a dilated CBD improves only partially after fluids and antibiotics. What is the priority definitive intervention?

Acute Cholangitis

72-year-old patient with fever, jaundice and right upper quadrant pain

A patient with fever, jaundice, hypotension and a dilated CBD improves only partially after fluids and antibiotics. What is the priority definitive intervention?

ERCP cannulation fails and the patient remains in septic shock. What is the best next principle?

After successful drainage, the patient develops recurrent fever and bilirubin elevation with a stent in place. Best next concern?

Definitive surgery is not always the first source-control maneuver.

Once sepsis and obstruction are controlled, address the underlying biliary disease.

Surgical Pearls

Pitfalls

A patient with severe cholangitis receives fluids and antibiotics but remains vasopressor-dependent with a distal common duct stone. What is the priority?