A previously healthy, 51-year-old Sri Lankan man presented with right upper quadrant colicky abdominal pain of 3 days’ duration. The pain was associated with yellow discoloration of the eyes, passage of dark urine, and generalized itching. He had no significant past medical, environmental, or social history. His clinical examination revealed that he was afebrile but had deep icterus, excoriations, and mild right upper quadrant abdominal tenderness. He had no stigmata of chronic liver disease. The results of laboratory investigations included a normal full blood count and inflammatory markers, deranged liver biochemistry (total bilirubin 6.4 mg/dl, ALP 325 IU/L, aspartate transaminase [AST] 113 U/L, ALT 318 U/L), normal liver function (serum albumin 3.8 g/dl, serum globulin 2.6 g/dl, INR 1.00, activated partial thromboplastin time [APTT] 29 seconds), and normal renal profile. An ultrasound scan (USS) of the abdomen showed the presence of cholelithiasis with features of chronic cholecystitis and a dilated CBD and intrahepatic ducts due to a distal CBD obstruction. Contrast-enhanced computed tomography of the abdomen confirmed the presence of a distal CBD stone causing proximal CBD and intrahepatic duct dilation and cholelithiasis. The patient underwent ERCP with sphincterotomy and balloon extraction of a CBD stone 2 weeks from the onset of symptoms. After surgery, the patient was given intravenous cefuroxime 750 mg three times daily for 1 day, followed by oral cefuroxime 500 mg twice daily for 5 days. The patient’s symptoms and biochemistry failed to improve, with worsening of cholestasis (total bilirubin 20.3 mg/dl, ALP 537 IU/L) following the “successful” therapeutic ERCP. Repeat ERCP 1 week later showed a normal CBD with no residual CBD stones. A 10-French, 10-cm CBD stent was inserted at this stage. The patient was then referred to a hepatologist for evaluation of worsening jaundice post-ERCP. By this time, the patient’s obstructive jaundice symptoms were severe and disabling, and biochemical analysis revealed worsening cholestasis (total bilirubin 39 mg/dl, ALP 651 IU/L), relatively normal liver enzymes (AST 61 U/L, ALT 62 U/L, gamma-glutamyltransferase [GGT] 25 U/L] with normal liver function (serum albumin 3.7 g/dl, serum globulin 1.9 g/dl, INR 1.00, APTT 29 seconds), normal full blood count, normal inflammatory markers, and normal renal profile. Repeat USS of the abdomen revealed multiple cholelithiasis, chronic cholecystitis, stent in the CBD, and no intrahepatic biliary radical dilation. Test results for the patient’s hepatitis A immunoglobulin M (IgM), hepatitis E antibodies, hepatitis B surface antigen, anti-hepatitis C antibodies, and Leptospira IgM antibodies were negative. On the basis of all the above-mentioned information, an ultrasound-guided liver biopsy was performed. The patient was commenced on prednisolone 40 mg daily, ursodeoxycholic acid 300 mg three times daily, and cholestyramine 5 g three times daily for symptomatic relief. A liver biopsy showed no evidence of portal tract edema or inflammation, lesions or paucity of bile ducts, bile infarcts or leaks, or inflammation or interphase hepatitis. However, there was marked bilirubinostasis in zone 3 canaliculi, with surrounding hepatocytes revealing feathery degeneration and surrounding inflammation. These features were compatible with intrahepatic cholestasis related to either drugs or sepsis. One week later, the patient developed fever with chills and rigors, worsening cholestasis clinically and biochemically (total bilirubin 48 mg/dl, ALP 901 IU/L) with relatively normal liver enzymes (AST 55 U/L, ALT 91 U/L, GGT 43 U/L), raised inflammatory markers (C-reactive protein 36 mg/dl), and neutrophil leukocytosis (white blood cell count 14,400/mm3 with 80% neutrophils). A clinical diagnosis of cholangitis was made, and the patient was commenced on intravenous meropenem 1 g three times daily, after blood cultures, for 14 days. The CBD stent was removed endoscopically to exclude the possibility of a blocked stent as the precipitant of cholangitis. Oral prednisolone was tapered rapidly in view of the infection. The cholangitis episode settled with the antibiotics, with resolution of fever and normalizing of full blood count and inflammatory markers. The patient’s cholestasis improved gradually over the next 2 months with ursodeoxycholic acid therapy. He had complete resolution of both clinical and biochemical features (total bilirubin 1.1 mg/dl, ALP 135 IU/L) of cholestasis 4 months into his illness. He was referred back to a hepatobiliary surgeon for elective laparoscopic cholecystectomy for residual cholelithiasis to prevent recurrence of complications and was advised to avoid cephalosporin use in the future. The timeline of the patient’s clinical course is presented in Table.