Aligned with the NCCPA format and updated blueprint. Authored & peer-reviewed by PA-Cs.
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A 75-year-old woman with a history of hypertension presents to the emergency department with right upper quadrant pain that has been gradually worsening over the past day. Her vital signs are T 103°F (39.4°C), BP 100/60 mm Hg, HR 100 bpm, RR 22/min, and SaO2 97% on room air. Physical exam reveals scleral icterus and right upper quadrant tenderness without rebound or guarding. A bedside right upper quadrant ultrasound demonstrates a common bile duct measuring 1 cm. Laboratory results are pending. What is the definitive management of this condition?
The patient presents with severe (suppurative) ascending cholangitis and requires biliary decompression with endoscopic retrograde cholangiopancreatography (ERCP). Ascending (or acute) cholangitis is a bacterial infection of the biliary system and is most frequently associated with common bile duct stones and obstruction. The disease classically presents with the Charcot triad (fever, jaundice, and right upper quadrant pain). However, only 50–75% of patients present classically, so clinicians must maintain a high index of suspicion for this life-threatening condition. While administration of broad-spectrum antibiotics is appropriate, those with signs of severe disease, including persistent abdominal pain, hypotension despite adequate fluid resuscitation, fever greater than 102°F (38.9°C), and confusion, warrant urgent ERCP.
Seventy to eighty percent of patients with ascending cholangitis will respond to broad-spectrum antibiotics (A) such as piperacillin-tazobactam. However, definitive management of this condition consists of biliary decompression. Cholecystectomy (B) may be required after disease resolution to prevent recurrent episodes but is no longer part of the definitive management of ascending cholangitis due to its highly associated mortality. Percutaneous transhepatic cholangiography (D) can be considered if ERCP is unavailable, unsuccessful, or contraindicated.
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Q: What is the recommended initial therapy for patients with primary biliary cholangitis?Reveal Answer
A: Ursodeoxycholic acid.
These bulleted reviews focus on condensed, high-yield concepts about the main topic, from patient presentation to preferred management.