A 65-year-old lady with good past health presents to the emergency department with a 2-day history of fever, jaundice and right upper quadrant pain. On further questioning, she has experienced pain on and off over the last few months.
•Temperature 39°C, pulse 115 bpm, BP 90/50mmHg, SaO2 98-100% on RA.
•Slightly dehydrated, jaundice.
•Examination of the hands reveals no clubbing, normal-appearing palmar creases and warm peripheries.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•Her chest is clear on auscultation.
•Abdominal examination reveals a soft abdomen, with right upper quadrant tenderness. Murphy’s sign is negative.
•No signs of oedema.
–WBC 19 x 109/L;
–platelets 296 x 109/L.
•Total bilirubin 100μmol/L.
•ALP 412 IU/L.
•ALT 102 IU/L.
•Blood culture to rule out septicaemia.
CXR shows no consolidative changes and no free gas under the diaphragm. ECG shows a normal sinus rhythm with no evidence of cardiac ischaemia.
What is your differential diagnosis?
•Acute cholangitis (most likely).
What would you do next?
The initial treatment of cholangitis should consist of:
•Aggressive fluid resuscitation 1.
•Prompt initiation of intravenous antibiotics 1.
•Correction of coagulopathy 1.
IV vitamin K1 is given. After fluid resuscitation with 1.5L colloid and initiation of IV cefotaxime, the patient remains tachycardic with a heart rate of 110 bpm. Blood pressure is 100/50mmHg after fluid resuscitation. Urgent ultrasound is not available.
How would you proceed?
In view of severe cholangitis with haemodynamic instability despite fluid resuscitation and intravenous antibiotics, an urgent endoscopic retrograde cholangiopancreatography (ERCP) should be considered.
An urgent ERCP is performed after initial stabilisation.
Fluoroscopy shows the following (Figure 28.1).
Please describe what you see
This is a limited fluoroscopic image of an ERCP showing a dilated common bile duct and intrahepatic ducts with three stones of at least 2cm in size in the common bile duct.
How would you proceed endoscopically?