Clinical record

A 66-year-old man with a history of ischaemic heart disease, hypertension and hypercholesterolaemia presented to a rural centre with a 2-week history of malaise, jaundice, right upper quadrant pain and daily rigors. Liver function tests revealed a raised bilirubin level (100 μmol/L; reference range [RR], 1–20 μmol/L) and abnormal levels of liver enzymes (alkaline phosphatase, 357 U/L [RR, 40–135 U/L]; γ-glutamyltransferase [GGT], 687 U/L [RR, 15–73 U/L]; alanine aminotransferase, 344 U/L [RR, 21–72 U/L]; aspartate aminotransferase, 216 U/L [RR, 17–59 U/L]). Results of serology tests for hepatitis B and C were negative. Full blood examination revealed a normal level of total white blood cells and mild thrombocytopenia (platelet count, 124 × 109/L [RR, 150–400 × 109/L]). Results of a computed tomography scan of the abdomen and pelvis were unremarkable. A presumptive diagnosis of acute cholangitis was made, and intravenous ceftriaxone (1 g daily) and metronidazole (500 mg every 8 h) therapy was initiated.

The patient had undergone a percutaneous coronary intervention with bare-metal stent placement about 2 months earlier, and had been prescribed clopidogrel (an antiplatelet agent; 75 mg daily) at this time. His other regular medications included aspirin, irbesartan–hydrochlorothiazide, simvastatin and omeprazole.