LAUSR

Suppurative cholangitis is a life-threatening condition requiring urgent decompression of the biliary tree [1]. Currently, endoscopic retrograde cholangiopancreatography (ERCP) is the standard method to drain the bile ducts. Herein, we present a novel method of radiationfree, direct endoscopic drainage of the common bile duct using transabdominal ultrasound. A 78-year-old woman with a history of hypertension, coronary artery disease, atrial fibrillation, and diabetes mellitus type II, and status post-cholecystectomy 20 years prior, presented with epigastric abdominal pain, fever, chills, and jaundice. On clinical examination she appeared ill and her blood pressure was 90/ 50mmHg with pulse of 100bpm. Laboratory data showed a white blood cell count of 20.03Gpt/L (normal range 4– 10), elevated liver tests, and cholestatic parameters. Glutamic oxaloacetic transaminase was 226U/L (< 42), glutamic pyruvic transaminase was 135U/L (< 40), alkaline phosphatase was 635U/L (< 78), international normalized ratio was 3.6, C-reactive protein was 314.3mg/L (< 5mg/L). On transabdominal ultrasound, a large amount of sludge was observed in a massively dilated common bile duct (▶Fig. 1). The intrahepatic bile ducts were also dilated (▶Video 1). The patient was admitted to the intermediate care unit and aggressive fluid resuscitation, intravenous vitamin K, and broadspectrum intravenous antibiotics (piperacillin/tazobactam) were administered. A diagnosis of bile stone-induced severe cholangitis (Tokyo criteria III) was made and a decision to perform an urgent ERCP was taken. Unfortunately, the Carm broke and no possibilities to use other X-ray equipment existed. As this admission occurred during the COVID-19 pandemic, it was impossible to transfer the patient to another hospital. The patient provided informed consent to E-Videos