When Current Severity Overrides Reassuring Findings: TG18 ‐Guided Biliary Drainage in ERCP ‐Confirmed Purulent Cholangitis

ABSTRACT A 42‐year‐old antibiotic‐naïve man with previous laparoscopic cholecystectomy and poorly controlled type 2 diabetes mellitus (HbA1c 9.7%) presented with Charcot's triad 7 days after a formally documented normal hepatobiliary evaluation (alanine aminotransferase [ALT] 22 U/L; total bilirubin 0.7 mg/dL [12 μmol/L]; common bile duct [CBD] ≤ 5 mm on ultrasound). Admission findings satisfied all three Tokyo Guidelines 2018 (TG18) diagnostic domains. Severity was Grade II on two of the five TG18 severity criteria—leukocytosis (14.2 × 10 3 /μL) and hyperbilirubinaemia (26 mg/dL, 445 μmol/L); temperature (38.9°C), age (42 years), and albumin (3.4 g/dL, 34 g/L) did not meet their thresholds, and no Grade III organ dysfunction was identified on the recorded variables. Grade II severity established the indication for early biliary drainage at presentation. Computed tomography (CT) showed only mild intrahepatic ductal dilatation with 3–4 hyperattenuating distal CBD filling defects (greatest ≈4 mm) and no dominant calculus. Immediate endoscopic retrograde cholangiopancreatography (ERCP) was not feasible because of endoscopy‐suite and anesthetic availability; antimicrobial and supportive therapy continued, and persistent clinical and biochemical abnormalities at 48 h (ALT 837 U/L; bilirubin 24 mg/dL, 410 μmol/L; C‐reactive protein 86 mg/L) reinforced the urgency of drainage during that interval. ERCP on Day 3, at the earliest available opportunity, showed macroscopic purulent bile at ductal entry, distal CBD filling defects, and copious biliary sludge on balloon sweep. Fever resolved within 24 h, and hepatobiliary and inflammatory markers normalized by 3 months (ALT 38 U/L; bilirubin 0.9 mg/dL, 15 μmol/L; C‐reactive protein < 5 mg/L). This case illustrates that current severity, not antecedent normality or unimpressive imaging, should govern the timing of biliary drainage, and it reports transparently an interval to drainage imposed by resource availability.