see also:

• ascending cholangitis is a life threatening condition which requires immediate Rx and is suggested by presence of fever, RUQ pain and jaundice (Charcot's triad)
• hepatitis
• cirrhosis
• liver diseases
• assessment of hepatic function
• neonatal jaundice

• if pain, fever and jaundice then Mx as per ascending cholangitis until proven otherwise
• if relatively well then
  • nil orally
  • iv fluids
  • FBE, U&E, LFT's, lipase, clotting
  • fluid balance chart
  • Rx coagulopathy with vitamin K
  • analgesia
  • consider admission under surgical unit or gastroenterology unit
  • DVT prophylaxis as indicated

• consider alternative diagnoses
• refer to gastroenterology
• consider CT-IVC, MRCP or EUS but these are generally low yield in this scenario

• if dilated CBD then likely CBD stone +/- cholecystitis
  • risk of ascending cholangitis
  • d/w gastro team
• if CBD not dilated:
  • DDx
    • acute cholecystitis
    • chronic cholecystitis
    • gallbladder neoplasm
    • if no cholecystitis, consider the rare Mirrizi syndrome:
      • impacted gallstone in cystic duct or neck of GB causes extrinsic compression of common hepatic duct
      • see Wikipedia
• ? MRCP/sphincterotomy +/- cholecystectomy

• CT pancreatic protocol
• tumour markers (CEA, CA19.9)
• refer to upper GIT surgery or gastroenterology

• requires further imaging:
  • if bilirubin < 30 then consider CT-IVC
  • if bilirubin > 30 then consider MCRP, or if no access to MRI then consider CTAP
  • if cholelithiasis detected Mx as above for cholelithiasis
  • if still no cholelithiasis detected then cholecystectomy may be indicated