The bloods show a mild neutrophilia and substantially deranged liver functions tests. She has jaundice, confirmed biochemically and the pattern of LFT derangement with all of the ALP, ALT and GGT elevated is a mixed one (suggesting both hepatitic and obstructive changes)

The most likely diagnosis given the clinical context is ascending cholangitis due to an obstruction of the lower  biliary tract. The most likely aetiology is a gallstone. Another important cause is a tumour involving the biliary tract or pancreas.

This patient has a life threatening emergency.

Her priorities in ED;

• Aggressive IV fluid resuscitation
• Nil by mouth and NG tube (if ongoing vomiting)
• Analgesia – titrated IV morphine or fentanyl
• Antibiotics – parenteral broad spectrum, for example  “triple therapy” amoxycillin /gentamycin / metronidazole

It is essential that her ongoing management be in a centre that can perform an ERCP as relief of her biliary obstruction is critical in resolution of the illness. The severity of such a presentation should not be underestimated. There is a significant mortality.