The patient has ascending cholangitis. After stabilization and initiation of antibiotics, the next most appropriate step is ERCP. The patient is high risk for postsphincterotomy bleeding as he is on three antithrombotic agents. The most prudent course of action is ERCP with stent placement. ERCP and stent placement is not contraindicated in patients on antithrombotic agents. This will allow for confirmation of the diagnosis as well as therapy for the obstruction. Once the patient has recovered, he can return on an elective basis, off antithrombotic agents, for definitive management of the common bile duct stone. MRCP would allow for a diagnosis; however, it is not therapeutic, and in the setting of cholangitis, management of the obstruction is necessary. Continued medical management neither provides information regarding diagnosis nor treats the obstruction. Percutaneous biliary drain would provide appropriate drainage but, as he is at a high risk for bleeding, ERCP with stent placement is a better therapeutic option in this patient.
1. Committee, ASGE Standards of Practice, et al. Management of anti-thrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009;70(6):1060-70.
2. Boustiere C., Veitch A., Vanbiervliet G., et al. Endoscopy and antiplatelet agents. Endoscopy. 2011;43(5):445-61.