What is the appropriate evaluation and management for an adult patient with no significant past medical history presenting with epigastric pain, chills, and jaundice?

Acute Cholangitis: Immediate Evaluation and Management

This clinical triad of epigastric pain, chills, and jaundice represents acute cholangitis until proven otherwise and requires urgent diagnostic confirmation followed by immediate antibiotic therapy and biliary drainage planning. 1, 2

Diagnostic Confirmation

The combination of fever/chills, epigastric/right upper quadrant pain, and jaundice constitutes Charcot's triad and is sufficient for clinical diagnosis when supported by laboratory and imaging findings. 1, 3

Essential laboratory workup includes:

• Total and fractionated bilirubin (conjugated hyperbilirubinemia expected) 4
• Complete blood count, inflammatory markers (elevated WBC, CRP) 1, 2
• Liver enzymes: AST, ALT, alkaline phosphatase, gamma-GT (elevated alkaline phosphatase and gamma-GT indicate cholestasis) 5, 4
• Albumin, PT/INR (assess hepatic synthetic function) 4

Initial Imaging Strategy

Obtain abdominal ultrasound immediately as the first-line imaging modality. 1, 2 Ultrasound has 80-90% sensitivity for identifying biliary dilatation and potential etiology (stones, strictures, masses). 2, 6

If ultrasound is equivocal or non-diagnostic but clinical suspicion persists, proceed directly to CT abdomen/pelvis with IV contrast. 1 CT achieves 90-95% sensitivity and is the recommended subsequent imaging when ultrasound fails to establish the diagnosis. 2

For cases where both ultrasound and CT remain inconclusive, obtain MRCP for definitive biliary anatomy visualization (95-100% sensitivity). 2 MRCP is particularly valuable when biliary obstruction is suspected but not confirmed on prior imaging. 1

Immediate Medical Management

Initiate broad-spectrum intravenous antibiotics within 1 hour of diagnosis. 2 This is a high-strength recommendation from the Infectious Diseases Society of America that directly impacts mortality.

Recommended antibiotic regimens include:

• Piperacillin/tazobactam
• Imipenem/cilastatin
• Meropenem
• Ertapenem

These agents provide coverage for gram-negative aerobes, enterococci, and anaerobes commonly causing biliary infections. 2 Continue antibiotics for 5-7 days. 2

Provide aggressive IV fluid resuscitation and hemodynamic monitoring to prevent organ dysfunction and septic shock. 2

Severity Assessment and Biliary Drainage Timing

Classify severity using the Tokyo Guidelines criteria to determine drainage urgency: 3

Severe (Grade III) cholangitis - presence of any new-onset organ dysfunction:

• Requires emergency biliary decompression immediately 2
• Emergency drainage improves outcomes by 50-70% 2
• Organ dysfunctions include cardiovascular (hypotension requiring vasopressors), neurologic (altered mental status), respiratory (PaO2/FiO2 <300), renal (oliguria, creatinine >2.0), hepatic (INR >1.5), or hematologic (platelets <100,000) 3

Moderate (Grade II) cholangitis - no organ dysfunction but failure to improve with initial treatment:

• Requires urgent biliary drainage within 24-48 hours if no clinical improvement or worsening occurs despite appropriate antibiotics 2
• Urgent drainage improves outcomes by 30-50% 2

Mild (Grade I) cholangitis - responds to initial medical treatment:

• Can proceed with semi-urgent drainage within 48-72 hours after clinical stabilization 3

Definitive Biliary Drainage

ERCP with sphincterotomy is the preferred drainage method with 90-95% success rate. 2 ERCP allows both diagnostic visualization and therapeutic intervention (stone extraction, stent placement). 2

Common etiologies requiring specific management:

• Choledocholithiasis (most common cause): ERCP with sphincterotomy and stone extraction achieves 80-90% success 2
• Malignant obstruction: ERCP with stent placement for palliation 7
• Benign strictures: ERCP with balloon dilation or stent placement 1

Post-Acute Management

After resolution of acute cholangitis from choledocholithiasis, perform cholecystectomy to prevent recurrence (reduces recurrence risk by 70-80%). 2 Delaying cholecystectomy after proven common bile duct stones carries 25.3% risk of unfavorable outcomes versus 12.7% with active treatment. 2

Critical Pitfalls to Avoid

Do not delay antibiotics while awaiting imaging confirmation - the clinical triad alone warrants immediate empiric therapy. 2, 5 Fever, chills, and jaundice with abdominal pain should trigger alarm for potential cholangitis or cholecystitis requiring urgent intervention. 5

Do not assume simple cholecystitis - the presence of jaundice distinguishes cholangitis (biliary obstruction with infection) from isolated cholecystitis. 1, 3

Do not use ultrasound alone to exclude cholangitis - while ultrasound is first-line, it has limitations and CT or MRCP may be necessary when clinical suspicion remains high despite negative or equivocal ultrasound. 1