A 32-year-old male with ulcerative colitis on azathioprine presents with acute high fever, severe right upper quadrant abdominal pain, and deep jaundice (Charcot triad). Lab results show total bilirubin 8.5 mg/dL, alkaline phosphatase 680 U/L, and WBC 18,500/uL. What is the immediate definitive therapeutic procedure?

Answer and explanation

Correct answer: D. Urgent endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage

  1. Step 1: Charcot triad (fever, RUQ pain, jaundice) signifies acute ascending bacterial cholangitis, a life-threatening infection.
  2. Step 2: Obstruction of the biliary tree creates high intraductal pressure, causing bacteremia and septic shock.
  3. Step 3: After initiating resuscitation and IV antibiotics, immediate biliary decompression via ERCP sphincterotomy/stenting is mandatory to prevent sepsis-related mortality.
Answer
Urgent endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage.
Why not the others: Cholecystectomy does not relieve common bile duct obstruction; liver biopsy during septic cholangitis is hazardous; steroids worsen sepsis.

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