A 72-year-old woman presents to the emergency department with 2 days of fever, chills, and worsening right upper quadrant abdominal pain. Her medical history is significant for cholelithiasis and type 2 diabetes mellitus. Medications include metformin and atorvastatin. Temperature is 38.8°C (101.8°F), blood pressure is 104/62 mm Hg, pulse is 112/min, and respiratory rate is 20/min. Physical examination reveals scleral icterus and right upper quadrant tenderness. Laboratory studies show a leukocyte count of 16,000/mm³, total bilirubin of 5.2 mg/dL, and alkaline phosphatase of 420 U/L.
Which of the following is the most appropriate next step in management?
The correct answer is:
A: Endoscopic retrograde cholangiopancreatography.
This patient has acute cholangitis, as evidenced by fever, jaundice, right upper quadrant pain, leukocytosis, and a cholestatic pattern of liver injury. The condition results from biliary obstruction complicated by infection. Management requires intravenous antibiotics and urgent biliary decompression, most commonly with ERCP.
Answer choice B: Immediate cholecystectomy, is incorrect.
Gallstones likely caused the obstruction, making surgery an attractive option. However, the immediate priority is relieving biliary obstruction and treating infection. Cholecystectomy is typically performed after stabilization if gallstones are the cause of the obstruction.
Answer choice C: Observation with outpatient follow-up, is incorrect.
Acute cholangitis can rapidly progress to sepsis and requires urgent treatment. Observation would place this patient at substantial risk.
Answer choice D: Oral proton pump inhibitor therapy, is incorrect.
PPIs are useful for acid-related disorders but do not treat biliary obstruction or infection.
Answer choice E: Repeat laboratory testing in 1 week, is incorrect.
Delaying treatment would allow ongoing obstruction and infection. Urgent intervention is necessary.
Key Learning Point
Acute cholangitis is a medical emergency characterized by fever, jaundice, and right upper quadrant pain that requires antibiotics and urgent biliary decompression.
