Ascending cholangitis — diagnosis, severity and drainage

This is acute ascending cholangitis until proven otherwise. Charcot triad (RUQ pain, fever, jaundice) is present, but diagnosis under Tokyo Guidelines 2018 rests on the three domains: systemic inflammation (fever/rigors ± raised WCC), cholestasis (jaundice or abnormal LFTs), and imaging evidence of biliary dilatation/obstruction — all fulfilled here with a dilated CBD and stone.^[1] Charcot triad is neither required nor highly sensitive; do not wait for the full triad.

Severity: TG18 Grade III (severe) because of cardiovascular dysfunction (hypotension) and neurological disturbance (confusion), with hypoperfusion (lactate 4.2). Grade III mandates urgent biliary drainage plus organ support, not antibiotics alone.^[1][5]

Immediate management (parallel):

1. Resuscitation bay, oxygen, monitoring, large-bore IV access; balanced crystalloid boluses for hypotension with reassessment.
2. Blood cultures ×2 if they do not delay therapy; VBG/ABG, FBC, U&E, LFT, coag, glucose.
3. Empiric antibiotics within the hour for biliary sepsis, e.g. ceftriaxone 2 g IV + metronidazole 500 mg IV (or piperacillin–tazobactam 4.5 g IV per local eTG/antibiogram for broader cover).^[3]
4. If MAP remains <65 after adequate fluid → noradrenaline, target MAP ≥65; early ICU involvement.
5. Urgent ERCP for CBD decompression and stone clearance (preferred source control). If ERCP unavailable/fails → percutaneous transhepatic biliary drainage (PTBD). Antibiotics do not replace drainage of an obstructed infected duct.^[5]
6. Analgesia; NBM; surgical/gastroenterology/ICU coordination; disposition = HDU/ICU for Grade III physiology.