Management of Choledocholithiasis with Septic Shock After ERCP
Wait until the sepsis resolves, and then perform cholecystectomy before discharge.
Initial Management Post-ERCP
- After successful ERCP with papillotomy for choledocholithiasis complicated by septic shock, the immediate focus should be on resolving the sepsis with appropriate antibiotic therapy and supportive care 1.
- Endoscopic biliary drainage through ERCP is the first-line procedure for biliary decompression in acute cholangitis due to its lower risk of adverse events compared to percutaneous or surgical drainage 1.
- The drainage of pus and bile stones from the common bile duct via papillotomy has addressed the immediate cause of sepsis, but definitive management requires cholecystectomy to prevent recurrence 1.
Timing of Cholecystectomy
- For patients with gallstone pancreatitis or cholangitis who have undergone successful ERCP with stone extraction, cholecystectomy should be performed during the same admission after sepsis has resolved 1.
- Early laparoscopic cholecystectomy (before discharge) is strongly recommended after gallstone pancreatitis to prevent recurrent episodes 1.
- Performing cholecystectomy before discharge (after sepsis resolution) reduces hospital readmissions and overall healthcare costs compared to delayed cholecystectomy 2, 3.
Evidence Supporting Early Cholecystectomy
- The 2020 WSES guidelines recommend that for patients with acute cholangitis who have undergone successful biliary drainage, cholecystectomy should be performed during the same hospitalization after sepsis resolves 1.
- Studies comparing early versus delayed laparoscopic common bile duct exploration show that early intervention is suitable for mild and moderate acute cholangitis, though caution is needed in severe cases 1.
- Waiting until sepsis resolves before performing cholecystectomy is critical, as operating during active sepsis significantly increases perioperative risks 1.
Contraindications to Early Cholecystectomy
- Persistent hemodynamic instability or ongoing sepsis despite adequate drainage and antibiotic therapy 1.
- Severe comorbidities making the patient unfit for surgery, in which case percutaneous cholecystostomy may be considered as an alternative 1.
- Evidence of multiple organ dysfunction that has not resolved despite appropriate treatment 1.
Follow-up Considerations
- After cholecystectomy, patients should be monitored for recurrent common bile duct stones, particularly those with risk factors such as bile duct diameter ≥15 mm or periampullary diverticulum 4.
- Post-ERCP complications occur in approximately 4% of cases, with pancreatitis (2.6%) being the most common 5.
- Routine follow-up with ultrasound is not necessary after successful ERCP and cholecystectomy unless there are persistent symptoms or laboratory abnormalities 1.
Conclusion for This Case
- Given that the patient has responded to ERCP with improved laboratory findings and pain relief, the most appropriate next step is to continue antibiotic therapy until sepsis resolves, followed by cholecystectomy during the same hospitalization 1.
- This approach minimizes the risk of recurrent biliary events while ensuring the patient is stable enough to undergo surgery safely 1, 3.