In a patient without a gallbladder who now has elevated bilirubin and a decreasing platelet count, what is the most likely diagnosis and what immediate management steps are indicated?

Acute Cholangitis: Immediate Diagnosis and Management

In a patient without a gallbladder presenting with elevated bilirubin and dropping platelets, acute cholangitis from choledocholithiasis (retained common bile duct stones) is the most likely diagnosis, and immediate management requires urgent biliary decompression via ERCP after initiating broad-spectrum antibiotics and fluid resuscitation. 1, 2

Most Likely Diagnosis: Acute Cholangitis

• Acute ascending cholangitis is a life-threatening infection of an obstructed biliary system, most commonly caused by common bile duct stones, and presents with fever, right upper quadrant pain, and jaundice (Charcot's triad). 2, 3

• The absence of a gallbladder does not eliminate the risk of bile duct stones—retained or recurrent choledocholithiasis occurs in 10-20% of post-cholecystectomy patients and remains the leading cause of biliary obstruction and cholangitis. 3, 4

• Dropping platelet count in this clinical context suggests systemic sepsis from biliovenous reflux of bacteria and purulent bile into the circulation, which occurs when increased biliary pressure forces infected bile across cellular barriers into the bloodstream. 2

• The hypercoagulable state paradoxically seen in obstructive jaundice (detected in 80% of patients by thromboelastography) does not protect against thrombocytopenia during sepsis, which reflects platelet consumption and bone marrow suppression from systemic infection. 5

Immediate Management Algorithm

Step 1: Resuscitation and Antibiotics (Within 1 Hour)

• Initiate aggressive IV fluid resuscitation immediately to address sepsis-related hypotension and maintain organ perfusion. 2, 3

• Start broad-spectrum IV antibiotics covering enteric flora within the first hour—use third-generation cephalosporins, ureidopenicillins, carbapenems, or fluoroquinolones with good bile duct penetration. 6, 2

• Obtain blood cultures before antibiotics, but do not delay antibiotic administration waiting for culture results in a septic patient. 2

Step 2: Diagnostic Imaging (Urgent, Within 6 Hours)

• Order abdominal ultrasound immediately as the initial imaging modality to confirm biliary dilatation and assess for choledocholithiasis, which has 71-97% specificity for mechanical obstruction. 6, 7

• If ultrasound shows dilated bile ducts or is equivocal, proceed directly to MRCP (sensitivity 85-100%, specificity 90% for choledocholithiasis) to definitively identify the level and cause of obstruction before therapeutic intervention. 6, 7

• CT abdomen is reserved only for critically ill patients with suspected complications such as liver abscess, emphysematous cholangitis, or perforation—it is inferior to ultrasound and MRCP for detecting bile duct stones. 6, 7

Step 3: Urgent Biliary Decompression (Within 24 Hours for Severe Cases)

• Patients with high-risk features (shock, altered mental status, organ dysfunction) require urgent biliary drainage within 24 hours, as they will not respond to antibiotics alone due to inadequate antibiotic penetration into obstructed bile. 1, 2

• ERCP with sphincterotomy is the preferred method of biliary decompression over percutaneous transhepatic biliary drainage (PTBD) or surgery, achieving successful stone removal in approximately 90% of cases with the lowest complication rate. 6, 1, 2, 4

• Endoscopic biliary drainage should be performed even before complete stone clearance in critically ill patients—initial drainage alone improves antibiotic penetration and reduces biliary pressure, with definitive stone extraction performed after clinical stabilization. 1, 2

Step 4: Mechanical Lithotripsy for Difficult Stones

• If standard ERCP with sphincterotomy fails to extract stones, mechanical lithotripsy successfully removes most remaining stones and should be attempted before considering more invasive alternatives. 6, 4

• Percutaneous or surgical approaches are reserved only for ERCP failures in patients with altered anatomy (prior gastric bypass, Billroth II) or upper GI obstruction preventing endoscopic access. 6, 1

Critical Clinical Pitfalls to Avoid

• Do not wait for MRCP results before starting antibiotics and fluids—imaging confirms the diagnosis but should never delay initial resuscitation in a septic patient. 2, 3

• Do not assume the absence of a gallbladder eliminates choledocholithiasis risk—retained or recurrent CBD stones are common and remain the leading cause of post-cholecystectomy cholangitis. 3, 4

• Do not rely on prothrombin time (PT) elevation alone to assess bleeding risk—obstructive jaundice paradoxically causes hypercoagulation in 80% of patients despite prolonged PT, and thrombocytopenia in sepsis reflects consumption, not coagulopathy. 5

• Do not perform diagnostic ERCP without therapeutic intent—if MRCP has already confirmed choledocholithiasis, proceed directly to therapeutic ERCP rather than repeating diagnostic cholangiography. 6

• Do not delay biliary decompression beyond 24 hours in patients with shock or organ dysfunction (Reynolds' pentad: Charcot's triad plus hypotension and altered mental status)—these patients have mortality rates exceeding 50% without urgent drainage. 2, 3

Prognosis and Follow-Up

• Overall prognosis depends on severity at presentation and rapidity of biliary decompression—patients who receive early drainage and appropriate antibiotics have excellent outcomes, while delayed intervention in severe cholangitis carries significant mortality. 2

• Definitive stone clearance should be confirmed after initial drainage and clinical stabilization, as incomplete stone extraction leads to recurrent cholangitis in up to 20% of cases. 4