DDSEP Quick Quiz

DDSEP® 8 Quick Quiz - February 2018 Question 2

A 76-year-old man presents with 2 days of epigastric abdominal pain radiating to the back accompanied by nausea, vomiting, fevers, and chills. His past medical history is notable for diabetes, hypertension, coronary artery disease, on clopidogrel and aspirin, as well as atrial fibrillation, for which he is on warfarin. Vital signs at presentation are temperature of 39.1°C, blood pressure of 88/58 mm Hg, and a heart rate of 110 beats per minute. Labs reveal a WBC count of 15,000/mm3, total bilirubin of 4.0 mg/dL, alkaline phosphatase of 234 IU/L, AST 120 IU/L, ALT 131 IU/L, and an INR of 2.7. An abdominal ultrasound reveals a common bile duct dilated to 1.5 cm.

Following fluid resuscitation and initiation of antibiotics, what is the next most appropriate step?

DDSEP® 8 Quick Quiz - February 2018 Question 2

ERCP with sphincterotomy

MRCP

ERCP with stent placement

Continue intravenous antibiotics with no further intervention

Percutaneous biliary drain

Answer: C

Rationale

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.

References

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.

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