Should I prioritize coronary angiogram or emergency ERCP in a patient with septic shock and elevated troponin levels due to ascending cholangitis?

Emergency ERCP Should Be Prioritized Over Coronary Angiogram in Septic Shock Due to Ascending Cholangitis

In a patient with septic shock due to ascending cholangitis and elevated troponin levels, emergency ERCP should be performed first before coronary angiogram to address the primary source of infection and improve survival.1, 2

Rationale for Prioritizing ERCP

• In severe cholangitis with septic shock, early biliary decompression is absolutely essential for survival and should be performed urgently 1
• Delayed biliary decompression (>12 hours after onset of shock) is significantly associated with increased mortality in cholangitis-associated septic shock 3
• ERCP is the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis (Grade 1A recommendation) 1
• Early biliary drainage in cholangitis significantly reduces mortality as well as local and systemic complications 1

Understanding Elevated Troponin in Sepsis

• Elevated troponin levels are common in sepsis and do not necessarily indicate primary coronary pathology requiring immediate intervention 4
• Troponin release in sepsis occurs in the absence of flow-limiting coronary artery disease and may be due to:
  • Direct cardiac myocytotoxic effects of endotoxins and cytokines 4
  • Microvascular dysfunction and regional wall motion abnormalities 4, 5
  • Ventricular wall strain due to sepsis-induced hemodynamic changes 5

Clinical Decision Algorithm

1. First priority: Emergency ERCP for biliary decompression

   • Should be performed within 12 hours of shock onset for optimal outcomes 3
   • Various endoscopic options include biliary stent or nasobiliary drain placement above the obstruction site ± sphincterotomy 1

2. Second priority: Stabilize the patient with appropriate antibiotics and supportive care

   • Start broad-spectrum antibiotics immediately (within hours) as delayed antimicrobial therapy is associated with increased mortality 3
   • Provide fluid resuscitation and vasopressor support as needed 3

3. Third priority: Consider coronary evaluation after biliary decompression and stabilization

   • Once the primary source of infection is controlled and the patient is hemodynamically stable 4, 5

Important Considerations

• If ERCP cannot be performed quickly or fails, consider percutaneous transhepatic biliary drainage (PTBD) as an alternative 1, 6
• PTBD should be reserved for patients in whom ERCP fails due to unsuccessful biliary cannulation or inaccessible papilla 1
• In severe septic shock, a lower threshold for percutaneous drainage should be considered, particularly if mobilization for ERCP is difficult 1

Potential Complications and Pitfalls

• Delaying biliary decompression beyond 12 hours significantly increases mortality in cholangitis with septic shock 3
• ERCP complications include pancreatitis (3.5%), hemorrhage (1.3%), and cholangitis (<1%) 2
• PTBD can lead to complications including biliary peritonitis, hemobilia, pneumothorax, and liver abscesses 1
• Focusing on elevated troponin without addressing the primary source of sepsis (cholangitis) may lead to delayed appropriate intervention and worse outcomes 4, 5