The primary etiology of ascending cholangitis is the obstruction of the biliary and pancreatic ducts allowing biliary stasis and microbial overgrowth [7]. The possible causes of post-cholecystectomy cholangitis range from pancreatic and biliary neoplasms, primary biliary stones from the liver, postoperative or autoimmune strictures, choledochal cysts, and biliary manipulation with ERCP or Percutaneous Transhepatic Cholangiogram (PTC) [7]. Charcot's triad encompasses the clinical features associated with cholangitis and consists of Right Upper Quadrant (RUQ) abdominal pain, jaundice, and fever [8]. The presence of symptoms of shock such as hypotension and tachycardia, and Altered Mental Status (AMS) make up Reynolds’ Pentad [8].

The initial diagnostic steps to diagnose cholangitis include RUQ ultrasound, and laboratory tests with a focus on leukocyte levels, serum transaminases, and bilirubin concentration [9]. The clinical picture formed by these results also acts as the alternative method of the diagnosis of acute cholangitis, whereas ERCP, PTC, and CT scans are then confirmatory [10]. In the setting of classical symptomatic presentation and lab results remarkable for obstruction and infection, the confirmatory tests, ERCP or PTC can be used to assess the underlying cause of obstruction [9]. ERCP is the initial test of choice due to its minimal invasiveness and decreased risk of hemoperitoneum and bile peritonitis when compared with PTC [11].

ERCP is characterized by advancing an endoscope orally into the duodenum [9]. After the endoscope has reached the duodenal papillae, cannulation, and fluoroscopy with contrast dye are conducted to allow radiographic visualization of the biliary and pancreatic tree structures for possible stones, strictures, or visceral masses that may cause extra ductal obstruction [9]. This tool is not only diagnostic but also therapeutic. Interventions are determined by the indications and include tissue sampling, removal of stones, fluid collection drainage, and tract repair via stent placement to restore ductal integrity [9]. Indications for ERCP include obstructive jaundice, neoplasms, stones, strictures, cysts, and ductal leakage [8]. In this case, the patient had obstructive jaundice characterized by elevated ALP and jaundice warranting ERCP. Although ERCP is therapeutic for acute obstructive cholangitis, in some cases, it increases the risk of acute cholangitis, making it the most common infectious adverse effect, and pancreatitis which is the most common noninfectious adverse event [12].

There are some contraindications to ERCP. These include i) bowel perforation, ii) unstable cardiac, pulmonary, or neurologic status, iii) altered gastrointestinal anatomy following gastric bypass procedure, and iv) severe uncorrected coagulopathy with an INR of >1.5 [13]. In this case, the patient’s INR was 3.9 and remained elevated despite numerous plasma transfusions. The presence of these contraindications may delay treatment and lead to complications ranging from worsening biliary symptoms to severe organ dysfunction involving the cardiovascular, nervous, respiratory, renal, hepatic, or hematological systems [14]. Some diagnostic alternatives to ERCP include endoscopic ultrasound (EUS) percutaneous cholangiography and Magnetic Resonance Cholangiopancreatography (MRCP) [15]. PTC, T-tube placement via laparotomy, and supportive management with antibiotics and fluids are notable alternative treatment options for ERCP [7]. In addition to medicinal therapy with antibiotics, ERCP remains the premier diagnostic and therapeutic mode of management of post-cholecystectomy cholangitis. Although the patient’s history and presentation and laboratory findings indicated that the best next step was ERCP, there were too many contraindications in this patient such as heart failure and increased PT and INR due to possible hepatic failure. It is important to implement medical optimization quickly to stabilize the patient and find alternatives for swift diagnosis and timely treatment in the management of post-cholecystectomy cholangitis.