Soru

A $68$-year-old woman is brought to the emergency department from a skilled nursing facility due to fever and altered mental status. For the past $48$ hours, she has had right upper quadrant abdominal pain and nausea. Her temperature is $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), blood pressure is $78/46 \text{ mm Hg}$, pulse is $128/\text{min}$, and respirations are $26/\text{min}$. Physical examination reveals scleral icterus and right upper quadrant tenderness without rebound or guarding. She is lethargic and oriented only to person. Laboratory studies show:

Leukocyte count: $22,000/\text{mm}^3$
Total bilirubin: $8.6 \text{ mg/dL}$
Direct bilirubin: $6.4 \text{ mg/dL}$
Alkaline phosphatase: $650 \text{ U/L}$
Aspartate aminotransferase (AST): $210 \text{ U/L}$
Alanine aminotransferase (ALT): $235 \text{ U/L}$
Lactic acid: $5.2 \text{ mmol/L}$

A right upper quadrant ultrasound demonstrates a dilated common bile duct measuring $15 \text{ mm}$ with an echogenic focus casting a posterior acoustic shadow in the distal duct. The gallbladder contains multiple stones but lacks wall thickening or pericholecystic fluid. She is given $3 \text{ L}$ of intravenous crystalloid and broad-spectrum antibiotics, but her blood pressure remains $80/50 \text{ mm Hg}$, necessitating the initiation of a norepinephrine infusion. Which of the following is the most appropriate next step in management?