Fever, Jaundice and Confusion at 02:00: Severe Cholangitis When ERCP Is Unavailable
A 71-year-old man presents at 02:00 with 36 hours of right upper quadrant pain, fever of 39.1 °C, and confusion that started this evening. He has hypertension, type 2 diabetes with HbA1c 8.6%, and atrial fibrillation on apixaban 5 mg twice daily, last dose 14 hours ago. Blood pressure is 88/54 mmHg, heart rate 118/min, respiratory rate 24/min, temperature 38.9 °C, GCS 14. The right upper quadrant is tender with a positive Murphy sign and no generalised peritonism. Investigations: white cell count 21.4 ×10⁹/L, platelets 88 ×10⁹/L, bilirubin 68 µmol/L, alkaline phosphatase 410 U/L, ALT 96 U/L, creatinine 168 µmol/L (baseline 90), lactate 3.4 mmol/L, INR 1.3. Bedside ultrasound shows a distended gallbladder with 6 mm wall thickening and pericholecystic fluid; the common bile duct measures 11 mm. No CT has been performed. The hospital's ERCP service runs on weekday mornings only, and it is Friday night. General surgery is on call.
1. State your working diagnosis and severity assessment, then set out the resuscitation and antimicrobial plan for the first hour, justifying each component.
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Diagnosis and grade. Acute cholangitis from choledocholithiasis with sepsis-induced organ dysfunction. He has Charcot's triad (fever, right upper quadrant pain, jaundice) plus confusion and hypotension, i.e. Reynolds' pentad. Using the Tokyo Guidelines 2018 he has organ dysfunction on several axes (altered consciousness, hypotension, platelets below 100 ×10⁹/L, creatinine well above baseline, lactate 3.4 mmol/L). That is severe (grade III) disease and mandates biliary drainage within 24 hours, not antibiotics alone.
First hour.
- Oxygen, two large-bore cannulae, and 500 mL balanced crystalloid boluses with reassessment after each. He is 71 with diabetes and possible diastolic dysfunction, so target a mean arterial pressure of 65 mmHg with 250–500 mL aliquots rather than reflexively giving 30 mL/kg.
- Two sets of blood cultures and urine culture, but never delay antibiotics for them.
- Piperacillin–tazobactam 4.5 g IV, dose-adjusted for creatinine 168 µmol/L, or ceftriaxone plus metronidazole. Choose a carbapenem only if there is prior healthcare exposure or ESBL risk. Avoid aminoglycosides with this acute kidney injury.
- Urinary catheter for hourly output, hourly lactate, venous gas, continuous monitoring.
- Vitamin K 10 mg IV, check fibrinogen; do not transfuse platelets for a number alone.
- No NSAIDs and no intramuscular injections while apixaban is active.
The key reasoning point is that antibiotics do not decompress an obstructed duct, so this hour buys time for drainage rather than replacing it.
2. Does he need biliary drainage tonight, and by what route? Justify your choice against ERCP on Monday, surgical decompression and other alternatives, taking account of platelets 88 ×10⁹/L and recent apixaban.
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Yes, drainage is needed tonight. Mortality in grade III cholangitis rises sharply when decompression is delayed beyond 24 hours, and waiting until Monday morning means roughly 55 hours of an obstructed, infected biliary tree in a hypotensive, confused patient. That is not defensible.
Route: percutaneous transhepatic biliary drainage (PTBD).
- He has dilated ducts (common bile duct 11 mm), which predicts technical success.
- Platelets 88 ×10⁹/L exceed the usual 50 ×10⁹/L threshold for percutaneous puncture, INR 1.3 is acceptable, and apixaban was last taken 14 hours ago in a patient without severe renal impairment, so drug levels are falling. Check an anti-Xa assay if available, use a right intercostal approach under ultrasound and fluoroscopy, avoid arterial puncture, and reserve prothrombin complex concentrate or andexanet for actual bleeding.
- The aim tonight is decompression, not stone clearance.
Why not the alternatives. Emergency choledochotomy carries a 20–30% mortality in grade III cholangitis and should be kept for failure or impossibility of less invasive drainage, or for a duct that cannot be accessed percutaneously. EUS-guided biliary drainage is reasonable only if a trained endosonographer is immediately available. Antibiotics plus observation until Monday is the option that must be explicitly rejected, and the reasoning should be documented in the notes.
3. ERCP on Monday clears two stones and inserts a plastic stent. Set out the definitive plan for cholecystectomy, the perioperative management of apixaban, and what you would do if he refuses surgery.
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Cholecystectomy. Once organ dysfunction has resolved (usually 24–72 hours) and the duct is clear, proceed to laparoscopic cholecystectomy during this admission or within six weeks. Roughly 20–30% of patients managed without cholecystectomy have a further biliary event within 6–12 weeks, and the delayed operation is technically harder after recurrent inflammation. Remove or exchange the plastic stent at 4–12 weeks if it was not removed at duct clearance.
Apixaban. For a laparoscopic cholecystectomy (moderate-to-high bleeding risk) with creatinine clearance above 50 mL/min, stop apixaban 48 hours before surgery, i.e. skip two doses. No heparin bridging is required for atrial fibrillation; the PAUSE-style approach is safer than bridging, which increases bleeding without reducing stroke. Restart 24 hours postoperatively if haemostasis is secure, and 48–72 hours if the field is bloody or conversion occurred.
If he refuses. Do not simply document refusal and discharge. Explain the recurrence risk in concrete terms, offer a surveillance plan, and record the discussion. For a patient who later proves unfit for surgery, percutaneous cholecystostomy is the salvage option for recurrent acute cholecystitis, not interval cholecystectomy. If he declines all intervention, the note should state that he will be reassessed urgently if symptoms recur, and the plastic stent still needs a planned removal date.