A 58-year-old man with fever, jaundice and right upper quadrant pain develops confusion and hypotension over 6 hours. Blood cultures are drawn and broad-spectrum antibiotics started. The most appropriate next step in management is:

• A Immediate laparoscopic cholecystectomy
• B Urgent biliary decompression by ERCP ✓
• C Percutaneous transhepatic cholecystostomy
• D CT abdomen with contrast before any intervention

Explanation

Charcot triad progressing to Reynolds pentad (addition of shock and altered mentation) defines acute suppurative ascending cholangitis from an obstructed common bile duct. Antibiotics alone fail because the source is an infected, pressurised biliary tree; mortality rises steeply without decompression. Urgent ERCP with sphincterotomy and stone extraction or stenting is first-line. Cholecystectomy treats the gallbladder, not the obstructed duct, and is deferred until sepsis settles. Percutaneous cholecystostomy is reserved when ERCP fails or is unavailable.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.