Biliary Poker: Simultaneous Presentation of Acute Calculous Cholecystitis, Choledocholithiasis, Acute Cholangitis, and Biliary Pancreatitis Managed via a Staged Endosurgical Approach: A Case Report

Background: The concurrent presentation of four distinct biliary complications—acute calculous cholecystitis, choledocholithiasis, acute cholangitis, and biliary pancreatitis—is an aggressive clinical entity colloquially or academically termed "Biliary Poker." Managing this synergistic compound requires a well-timed, staged therapeutic approach to balance urgent decompression against systemic risks. Case Description: A 50-year-old female patient presented with an 8-day history of acute, severe abdominal pain in the right upper quadrant, accompanied by jaundice, choluria, and acholia. Initial emergency laboratories revealed a severe obstructive cholestatic pattern (Total Bilirubin [TB]: 12.5 mg/dL) with normal pancreatic enzymes (Lipase: 53 U/L), confirming choledocholithiasis and moderate acute cholangitis. During her fourth day of hospitalization, an in-hospital calculous migration triggered a clinical shift into a full "Biliary Poker" compound, with serum lipase skyrocketing to 39,390 U/L and amylase reaching 5,315 U/L. An urgent Endoscopic Retrograde Cholangiopancreatography (ERCP) was performed; cholangiography demonstrated a dilated biliary tree (common bile duct: 11.3 mm, common hepatic duct: 9.6 mm) with multiple filling defects. A wide sphincterotomy and extraction balloon sweeps achieved complete stone clearance and decompression. Following full clinical and biochemical recovery (Lipase normalized to 112 U/L, TB decreased to 1.8 mg/dL), a definitive laparoscopic cholecystectomy was performed on March 9, 2026. The transoperatorial course was uneventful, verifying acute-on-chronic calculous cholecystitis. The patient was discharged in excellent condition. Conclusion: "Biliary Poker" is a high-risk surgical emergency. A sequential, step-up management strategy consisting of emergency endoscopic decompression followed by delayed laparoscopic clearance effectively minimizes operative risks and yields optimal survival rates.