In this episode of Hospital Medicine Unplugged, we demystify acute choledocholithiasis—who needs urgent decompression, how to clear the duct, and how to prevent the encore.

We open with the sick first: suspected cholangitis or biliary sepsis = urgent ERCP (<24 h) for decompression and cultures, alongside IV fluids and broad-spectrum antibiotics. If ERCP fails or isn’t feasible, pivot to EUS-guided or percutaneous drainage.

Then the risk tiers that steer the workup (ASGE):
High risk (stone seen, cholangitis, or bili >4 mg/dL plus CBD dilation) → straight to ERCP.
Intermediate risk → EUS or MRCP (pick by availability/expertise) or IOC.
Low risk → lap chole with selective IOC.

Diagnostics that matter: RUQ ultrasound first; MRCP/EUS confirm stones when the pretest probability is mid-range. Use IOC intraop when pre-op imaging is equivocal—if stones are there, you’ve got options.

Therapy playbook—choose your lane:
• Endoscopic lane (two-stage): pre-op ERCP + sphincterotomy + extraction, then same-admission lap chole.
• Single-stage surgical lane: lap chole + ductal clearance via LCBDE (transcystic or transductal) or intraoperative ERCP (rendezvous). When available, this shortens LOS and avoids a second anesthesia.
• Big stones/difficult duct: add papillary balloon dilation, mechanical lithotripsy, or place a temporary stent with plan for delayed clearance.

Aftercare that prevents bounce-backs: index-admission cholecystectomy is the rule after clearance (delay only for unstable or necrotizing pancreatitis). If a stent was placed, schedule removal/exchange in 2–6 months—don’t lose the patient to follow-up. Monitor LFTs and symptoms; educate on when to call.

What ERCP buys you: rapid source control and high clearance, at the cost of post-ERCP pancreatitis, bleeding, infection, perforation (mitigate with rectal indomethacin and wire-guided cannulation; PD stent if high risk).

Special situations you’ll actually encounter:
• Gallstone pancreatitis: ERCP only for cholangitis or ongoing obstruction; otherwise straight to same-admission chole with selective IOC.
• Elderly/frail or nonsurgical candidates: ERCP ± stent as definitive therapy; plan structured stent exchanges.
• Altered anatomy/failed ERCP: EUS-BD (if expertise) or PTC.

We close with the system moves: a Choledocholithiasis pathway that (1) auto-tiers ASGE risk, (2) default-orders EUS/MRCP for intermediates, (3) fast-tracks urgent ERCP for cholangitis, (4) hardwires same-admission chole post-clearance, and (5) creates a stent registry/tickler with due dates. Add an ERCP note template with stone size/number, clearance status, and explicit chole plan.

Crisp, guideline-driven, and bedside-ready—exactly what your team needs to clear the duct and keep it cleared.