What to do for a patient with gallstones, fever, and jaundice?

Management of Gallstones with Fever and Jaundice

This patient requires urgent ERCP with sphincterotomy under antibiotic cover, followed by cholecystectomy within 2-4 weeks—not immediate cholecystectomy. 1, 2

Clinical Recognition and Initial Assessment

This presentation of gallstones with fever and jaundice indicates acute cholangitis or gallstone pancreatitis with biliary obstruction, both of which are medical emergencies requiring immediate intervention. 1, 2

• Obtain liver function tests immediately, including direct and indirect bilirubin, AST, ALT, ALP, and GGT 3
• Perform abdominal ultrasound urgently to identify gallstone disease and assess for biliary obstruction 1, 4
• Obtain blood, urine, and ascites cultures (if present) to identify bacterial infections, regardless of fever presence 3
• Assess severity using clinical impression, APACHE II score, or C-reactive protein >150 mg/L after 48 hours 1, 2

Immediate Management Algorithm

Step 1: Start Broad-Spectrum Antibiotics Immediately

Begin parenteral broad-spectrum antibiotics immediately upon suspicion of cholangitis, adapted subsequently to bile and blood cultures. 3

• First-line options include piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem 3
• Add amikacin if associated shock is present 3
• Continue antibiotics for 4 days after source control by biliary decompression 3

Step 2: Perform Urgent ERCP with Sphincterotomy

Perform immediate therapeutic ERCP with sphincterotomy within 24-72 hours under antibiotic cover in patients with cholangitis (fever + jaundice + gallstones). 1, 2

• This is a Grade A recommendation with high strength of evidence 1
• ERCP must be performed under antibiotic cover to prevent infection 5
• Never delay ERCP in patients with cholangitis, as this leads to increased morbidity and mortality 1

Step 3: Supportive Care During Acute Phase

• Admit severe cases to HDU or ICU with full monitoring including CVP, arterial blood gases, hourly vital signs, oxygen saturation, and urine output 1
• Provide aggressive fluid resuscitation and hemodynamic support 1
• Avoid nephrotoxic drugs including diuretics, as acute kidney injury is an early manifestation of multi-organ failure 3

Definitive Management After Acute Phase Resolution

Schedule laparoscopic cholecystectomy within 2-4 weeks, preferably during the same hospital admission, once the inflammatory process has subsided. 1, 2, 5

• Delaying cholecystectomy beyond 2 weeks increases the risk of recurrent biliary events by 56%, including potentially fatal recurrent pancreatitis 2
• Preoperative assessment should include repeat liver biochemistry and ultrasound examination of the common bile duct 2, 5
• For patients unfit for surgery due to high surgical risk, ERCP with sphincterotomy alone is adequate definitive treatment 2, 5

Critical Pitfalls to Avoid

• Do not perform immediate cholecystectomy in the setting of acute cholangitis or severe inflammation—this significantly increases surgical risk and complications 1, 5
• Do not give only antibiotics without biliary drainage—source control via ERCP is essential for cholangitis 3, 1
• Do not delay ERCP beyond 72 hours in patients with cholangitis, as mortality increases significantly 1, 2
• Do not discharge without scheduling definitive cholecystectomy, as recurrent biliary events occur in over half of patients if surgery is delayed beyond 2 weeks 2

Why the Answer is NOT Immediate Cholecystectomy

The presence of fever and jaundice indicates active infection and biliary obstruction, making immediate cholecystectomy technically dangerous with higher complication rates. 1, 5 The correct sequence is: (1) antibiotics, (2) urgent ERCP for biliary decompression, (3) delayed cholecystectomy after inflammation subsides. 1, 2, 5