Acute Cholangitis

1. Clinical Overview

Summary

Acute cholangitis is a life-threatening systemic infection arising from bacterial contamination of an obstructed biliary tree. It represents a true medical emergency requiring prompt recognition, resuscitation, antimicrobial therapy, and urgent biliary decompression to prevent progression to septic shock, multi-organ failure, and death. [1,2]

The classic clinical presentation is Charcot's triad: fever with rigors, right upper quadrant (RUQ) pain, and jaundice. However, this complete triad is present in only 50-70% of patients. [3] Severe cholangitis manifests as Reynolds' pentad, with the addition of hypotension and altered mental status, indicating septic shock with mortality rates approaching 30% without urgent intervention. [4]

The most common aetiology is choledocholithiasis (common bile duct stones), accounting for 50-70% of cases. [5] Other causes include benign and malignant biliary strictures, post-procedural complications (particularly post-ERCP), biliary stent occlusion, and parasitic infections in endemic regions. [6]

The Tokyo Guidelines (TG18/TG21) provide an internationally accepted framework for diagnosis, severity assessment, and management, stratifying patients into mild (Grade I), moderate (Grade II), and severe (Grade III) categories based on the presence of organ dysfunction. [1,7] This severity grading directly determines the urgency of biliary drainage and the need for intensive care admission.

Key management principles include early recognition, adherence to sepsis bundles, empirical broad-spectrum antibiotics covering Gram-negative enterobacteriaceae and anaerobes, and timely biliary drainage—preferably via endoscopic retrograde cholangiopancreatography (ERCP). [8,9] Percutaneous transhepatic cholangiography (PTC) serves as the primary alternative when ERCP is unsuccessful or anatomically inaccessible. [10]

Key Facts

Clinical Pearls

"Charcot's Is Only Half the Story": The classic triad is absent in 30-50% of cases. Maintain a high index of suspicion in any patient with unexplained sepsis, jaundice, or RUQ discomfort—especially the elderly or immunosuppressed who may present atypically. [3,11]

"Reynolds' Pentad = Immediate Action": Hypotension and confusion added to Charcot's triad indicates severe cholangitis with high mortality. This constitutes a surgical/endoscopic emergency requiring ICU admission, aggressive resuscitation, and urgent biliary drainage within 12-24 hours. [4]

"Stone Disease Dominates, But Think Wider": CBD stones cause the majority of cases, but always consider post-ERCP complications, biliary stent occlusion in malignancy patients, benign strictures (PSC, chronic pancreatitis), and parasites (Ascaris, Clonorchis, Opisthorchis) in endemic regions. [5,6]

"Drain the Bile, Save the Life": Antibiotics alone are insufficient. The obstructed, infected biliary system must be decompressed. ERCP is first-line; PTC if ERCP fails or is anatomically inaccessible (e.g., post-Roux-en-Y, duodenal obstruction). [8,9,10]

"TG18 Severity = Timing": Tokyo Guidelines Grade III (organ dysfunction) requires drainage within 24 hours and often immediate (within 12 hours); Grade II (moderate) within 24-48 hours; Grade I (mild) can be semi-elective once stabilised on antibiotics. [1,7]

"Blood Cultures Before Antibiotics—But Don't Delay": Obtain cultures promptly, but initiation of antibiotics should not wait. Target administration within 1 hour of recognition, as per sepsis guidelines. Positive blood cultures in 40-80% guide subsequent therapy. [12,13]

"Biliary Penetration Matters": Choose antibiotics with good biliary penetration. Piperacillin-tazobactam achieves excellent concentrations; aminoglycosides penetrate poorly in obstruction. De-escalate based on culture sensitivities. [14]

Why This Matters Clinically

Acute cholangitis carries significant morbidity and mortality, particularly when recognition or intervention is delayed. Early studies reported mortality rates exceeding 50% with conservative management alone, which dramatically decreased to under 10% with the advent of interventional biliary drainage. [2,8] The Tokyo Guidelines have standardised diagnosis and management, improving outcomes through consistent severity-based algorithms. [1]

Every clinician—from emergency physicians to intensivists to surgeons—must recognise Charcot's triad, initiate the sepsis pathway, and urgently involve gastroenterology or hepatobiliary surgery for drainage. Understanding the Tokyo severity criteria allows appropriate triage: mild cases can be stabilised and drained semi-electively, while severe cases require immediate ICU transfer and emergency ERCP or PTC. [7,9]

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2. Epidemiology

Incidence and Prevalence

Acute cholangitis is a common biliary emergency, though precise incidence data vary due to differences in definition and reporting. It occurs in approximately 1-2% of patients with symptomatic choledocholithiasis. [5]

Demographics

Risk Factors

Temporal Trends

The incidence of cholangitis has evolved with changing patterns of biliary intervention:

• Increased ERCP-related cholangitis as endoscopic procedures have become more common [15]
• Decreased post-cholecystectomy cholangitis with improved surgical techniques and intraoperative cholangiography
• Rising incidence in the elderly due to demographic ageing and increased comorbidities
• Increased stent-related cholangitis with wider use of biliary stenting for palliation of malignant obstruction [6]

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3. Aetiology

Primary Causes

Acute cholangitis requires two conditions: biliary obstruction and bacterial contamination of the biliary tree. [1]

Choledocholithiasis (CBD Stones)

CBD stones are the predominant cause worldwide. [5] They may be:

• Primary: Form within the bile ducts (brown pigment stones, associated with infection/stasis)
• Secondary: Migrate from the gallbladder (cholesterol or black pigment stones)

Risk factors for CBD stones include advanced age, larger gallstones, longer cystic duct, and concurrent gallbladder disease.

Malignant Causes

Biliary obstruction from malignancy predisposes to cholangitis, particularly:

• Pancreatic adenocarcinoma (head of pancreas)
• Cholangiocarcinoma (hilar/Klatskin, distal, intrahepatic)
• Ampullary carcinoma
• Gallbladder carcinoma with CBD invasion
• Metastatic disease (porta hepatis lymphadenopathy)

Patients with malignant obstruction and biliary stents are at particularly high risk due to stent occlusion and tumour progression. [6]

Benign Strictures

Post-Procedural Cholangitis

Cholangitis following biliary interventions is a recognised complication: [15]

• Post-ERCP: Incidence 0.5-3%; higher with incomplete stone clearance, contrast injection into obstructed ducts
• Post-PTC: Risk of bile leak and infection
• Post-Cholecystectomy: Retained CBD stones, bile duct injury

Parasitic Causes

Common in East and Southeast Asia: [6]

• Ascaris lumbricoides: Roundworm migration into biliary tree
• Clonorchis sinensis: Chinese liver fluke
• Opisthorchis viverrini: Southeast Asian liver fluke
• Fasciola hepatica: Sheep liver fluke (less common)

These cause recurrent cholangitis, intrahepatic stone formation, and predispose to cholangiocarcinoma.

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4. Pathophysiology

Mechanism of Disease

The development of acute cholangitis requires the combination of biliary obstruction and bacterial presence in the bile ducts. [1,16]

Step 1: Biliary Obstruction

• Mechanical obstruction (stone, stricture, tumour, stent occlusion)
• Increased intraductal pressure (normal: 7-14 cmH2O; in obstruction: 25-30+ cmH2O)
• Bile stasis creates a favourable environment for bacterial proliferation
• Impaired biliary flow prevents washout of bacteria

Step 2: Bacterial Colonisation

Normal bile is sterile. Bacteria enter the biliary tree via: [16]

• Ascending route (most common): Bacteria from duodenum ascend through the sphincter of Oddi
• Portal venous route: Translocation from intestinal flora
• Lymphatic route: Less common
• Haematogenous route: Rarely, from distant infection

Sphincter of Oddi dysfunction, prior sphincterotomy, and biliary-enteric anastomoses increase ascending infection risk.

Step 3: Infection and Inflammation

• Bacterial multiplication in obstructed bile
• Inflammatory response in bile duct wall (acute cholangitis)
• Purulent bile accumulation (suppurative cholangitis in severe cases)
• Release of bacterial endotoxins (lipopolysaccharide from Gram-negatives)

Step 4: Cholangio-Venous and Cholangio-Lymphatic Reflux

• Critical step: Elevated biliary pressure (> 25 cmH2O) causes reflux of infected bile into:
  • Hepatic venous sinusoids (cholangio-venous reflux)
  • Peribiliary lymphatics (cholangio-lymphatic reflux)
• Systemic bacteraemia and endotoxaemia
• Blood culture positivity in 40-80% of patients [12,13]

Step 5: Systemic Inflammatory Response

• SIRS → Sepsis → Severe Sepsis → Septic Shock
• Cytokine storm (IL-1, IL-6, TNF-alpha)
• Endothelial dysfunction and capillary leak
• Vasodilation and hypotension
• Tissue hypoperfusion and organ dysfunction

Step 6: Organ Failure (Severe/Grade III)

Without intervention, progression to: [4]

• Cardiovascular: Distributive shock requiring vasopressors
• Neurological: Encephalopathy from sepsis and hepatic dysfunction
• Respiratory: ARDS
• Renal: Acute kidney injury from hypoperfusion
• Hepatic: Worsening jaundice, coagulopathy
• Haematological: DIC, thrombocytopenia
• Death: Multi-organ failure

Key Pathophysiological Concepts

Common Organisms

The microbiology of acute cholangitis reflects the enteric origin of bacteria: [12,14,16]

Polymicrobial infection is common (30-50% of cases), particularly in healthcare-associated cholangitis and patients with biliary stents. [14]

Antibiotic resistance is increasing, especially:

• Extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae
• Vancomycin-resistant Enterococcus (VRE)
• Multi-drug resistant Pseudomonas (healthcare-associated)

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5. Clinical Presentation

Symptoms

Signs

Charcot's Triad vs Reynolds' Pentad

Atypical Presentations

Be vigilant for atypical presentations in: [3,11]

• Elderly patients: May present with confusion, falls, or functional decline without classic triad
• Immunosuppressed patients: Blunted fever response, subtle signs
• Patients on corticosteroids: Suppressed inflammatory response
• Patients with malignancy: May have gradual onset due to progressive obstruction
• Post-procedure patients: May develop cholangitis 24-72 hours after ERCP

Red Flags — Severe Cholangitis (Tokyo Grade III)

[!CAUTION] Emergency Features Requiring Immediate Escalation:

• Cardiovascular dysfunction: Hypotension requiring vasopressor support (dopamine > 5 mcg/kg/min or any noradrenaline)
• Neurological dysfunction: Altered consciousness, confusion, GCS less than 15
• Respiratory dysfunction: PaO2/FiO2 ratio less than 300, requiring high-flow oxygen or ventilatory support
• Renal dysfunction: Oliguria (less than 0.5 mL/kg/hr), creatinine > 2.0 mg/dL (> 177 μmol/L)
• Hepatic dysfunction: INR > 1.5, PT prolongation not responding to vitamin K
• Haematological dysfunction: Platelets less than 100,000/mm3
• Lactate > 2 mmol/L: Tissue hypoperfusion

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6. Clinical Examination

Initial Assessment (ABCDE Approach)

Airway

• Patent and maintained
• Consider protection if GCS reduced

Breathing

• Respiratory rate, oxygen saturation
• Signs of respiratory distress or ARDS
• Auscultation: basal crackles may indicate early ARDS

Circulation

• Blood pressure (hypotension indicates severity)
• Heart rate (tachycardia in sepsis)
• Capillary refill time (> 2 seconds suggests hypoperfusion)
• Peripheral perfusion and temperature
• ECG if cardiac comorbidities or severe sepsis

Disability

• Glasgow Coma Scale
• Pupil examination
• Blood glucose (hypoglycaemia in severe sepsis)

Exposure

• Temperature measurement
• Full abdominal examination
• Skin: jaundice, rashes, petechiae (DIC)

Abdominal Examination

Skin and General Examination

Severity Assessment: Tokyo Guidelines (TG18/TG21)

The Tokyo Guidelines provide standardised severity grading that directly informs management timing: [1,7]

Grade I (Mild)

Definition: Acute cholangitis that does not meet Grade II or III criteria

Characteristics:

• Responds to initial medical treatment (antibiotics + supportive care)
• No organ dysfunction
• No features of moderate severity

Management:

• Antibiotic therapy
• Biliary drainage can be delayed until workup complete
• Semi-elective ERCP (within 48-72 hours if responding)

Grade II (Moderate)

Definition: Presence of any TWO of the following:

Characteristics:

• Does not respond rapidly to initial treatment
• Requires early biliary drainage
• Higher risk of progression to severe

Management:

• Biliary drainage within 24-48 hours
• May need HDU/enhanced monitoring
• Early involvement of endoscopy/IR

Grade III (Severe)

Definition: Presence of organ dysfunction in ANY ONE system:

Characteristics:

• Life-threatening
• Requires ICU admission
• Emergency biliary drainage

Management:

• ICU admission with organ support
• Urgent biliary drainage (within 24 hours; ideally within 12 hours)
• Vasopressor support as needed
• May require mechanical ventilation, renal replacement therapy

Quick Severity Assessment Algorithm

                    SUSPECTED CHOLANGITIS
                           ↓
            ┌─────────────────────────────────┐
            │    ANY ORGAN DYSFUNCTION?        │
            │  (CV, Neuro, Resp, Renal,        │
            │   Hepatic, Haematological)       │
            └─────────────────────────────────┘
                    ↓ YES              ↓ NO
            ┌───────────────┐    ┌───────────────────┐
            │   GRADE III   │    │ ANY 2 of:         │
            │    (SEVERE)   │    │ WCC > 12/less than 4        │
            │               │    │ Fever > 39°C       │
            │ ICU + Urgent  │    │ Age ≥75           │
            │ ERCP less than 24h     │    │ Bili ≥5mg/dL      │
            └───────────────┘    │ Albumin low       │
                                 └───────────────────┘
                                   ↓ YES      ↓ NO
                           ┌─────────────┐ ┌───────────┐
                           │  GRADE II   │ │ GRADE I   │
                           │ (MODERATE)  │ │  (MILD)   │
                           │             │ │           │
                           │ ERCP 24-48h │ │ ERCP when │
                           │             │ │ available │
                           └─────────────┘ └───────────┘

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7. Investigations

Tokyo Guidelines Diagnostic Criteria (TG18)

Definite diagnosis requires items from ALL THREE categories: Suspected diagnosis requires items from any TWO categories

Laboratory Investigations

First-Line Blood Tests

Severity Assessment Tests

Microbiological Investigations

Imaging Investigations

First-Line: Transabdominal Ultrasound (USS)

Advantages: Non-invasive, bedside availability, no radiation, low cost Limitations: Operator-dependent, CBD stones often missed, gas obscures distal CBD

CT Abdomen with Contrast

Indications:

• USS inconclusive
• Suspected malignant obstruction
• Suspected complications (abscess, perforation)
• Pre-operative planning

MRCP (Magnetic Resonance Cholangiopancreatography)

Indications:

• Intermediate probability of CBD stones
• Characterisation of strictures
• When ERCP may be avoided
• Pre-operative planning for complex cases

Advantages: Non-invasive, no radiation, high accuracy for stones Limitations: Cost, availability, cannot be therapeutic

ERCP (Endoscopic Retrograde Cholangiopancreatography)

ERCP is both diagnostic AND therapeutic and remains the gold standard intervention: [8,9]

Success rate: 90-95% for biliary cannulation and drainage Complications: Pancreatitis (3-5%), bleeding (1-2%), perforation (less than 1%), cholangitis (1-3%)

EUS (Endoscopic Ultrasound)

Indications:

• Intermediate probability CBD stones when MRCP unavailable
• FNA for suspected malignancy
• Before planned ERCP to confirm indication

Diagnostic Algorithm

                    SUSPECTED CHOLANGITIS
                           ↓
        ┌──────────────────────────────────────────┐
        │  IMMEDIATE: Bloods (FBC, LFTs, CRP,      │
        │  Lactate, Coag, U&E, Blood cultures x2)  │
        └──────────────────────────────────────────┘
                           ↓
        ┌──────────────────────────────────────────┐
        │        URGENT ABDOMINAL ULTRASOUND       │
        │  Look for: CBD dilatation, gallstones,   │
        │  CBD stones, abscess                     │
        └──────────────────────────────────────────┘
                           ↓
            ┌──────────────┴──────────────┐
            ↓                             ↓
    ┌───────────────┐            ┌───────────────────┐
    │ DEFINITE      │            │ SUSPECTED BUT     │
    │ CHOLANGITIS   │            │ IMAGING UNCLEAR   │
    │               │            │                   │
    │ Proceed to    │            │ Consider:         │
    │ severity      │            │ - CT abdomen      │
    │ grading and   │            │ - MRCP            │
    │ ERCP          │            │ - EUS             │
    └───────────────┘            └───────────────────┘

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8. Differential Diagnosis

Primary Differentials

Must Not Miss

[!WARNING] Conditions that present similarly but require different management:

• Perforated peptic ulcer: Free air on erect CXR/CT
• Ruptured AAA: Pulsatile mass, hypotension, back pain
• Mesenteric ischaemia: Pain out of proportion, metabolic acidosis, raised lactate
• Acute pancreatitis with biliary sepsis: May coexist; manage both

Overlap Syndromes

Common clinical scenarios with overlapping features:

• Cholangitis + Cholecystitis: CBD stone with concurrent GB inflammation
• Cholangitis + Pancreatitis: Stone impacted at ampulla causing both
• Cholangitis + Liver Abscess: Complication of untreated/undertreated cholangitis

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9. Management

Emergency Management Algorithm

                         ACUTE CHOLANGITIS
                              ↓
┌────────────────────────────────────────────────────────────────────┐
│                    RESUSCITATION (SEPSIS-6 BUNDLE)                  │
├────────────────────────────────────────────────────────────────────┤
│  1. HIGH-FLOW OXYGEN (target SpO2 94-98%)                          │
│  2. BLOOD CULTURES (x2 sets, before antibiotics)                   │
│  3. IV BROAD-SPECTRUM ANTIBIOTICS (within 1 hour)                  │
│  4. IV FLUID RESUSCITATION (crystalloid 30 mL/kg if hypotensive)   │
│  5. CHECK SERUM LACTATE                                            │
│  6. MONITOR URINE OUTPUT (catheterise if oliguric/severe)          │
└────────────────────────────────────────────────────────────────────┘
                              ↓
┌────────────────────────────────────────────────────────────────────┐
│                    SEVERITY ASSESSMENT (TG18)                       │
├────────────────────────────────────────────────────────────────────┤
│  GRADE III (Severe): Any organ dysfunction → ICU + Urgent ERCP     │
│  GRADE II (Moderate): 2+ risk factors → HDU + Early ERCP           │
│  GRADE I (Mild): Stable → Ward + Semi-elective ERCP                │
└────────────────────────────────────────────────────────────────────┘
                              ↓
┌────────────────────────────────────────────────────────────────────┐
│                       BILIARY DRAINAGE                              │
├────────────────────────────────────────────────────────────────────┤
│  FIRST-LINE: ERCP                                                   │
│  ➤ Sphincterotomy + stone extraction                               │
│  ➤ Biliary stent if complete clearance not possible                │
│  ➤ Nasobiliary drain for severe/pus drainage                       │
│                                                                     │
│  SECOND-LINE: Percutaneous Transhepatic Cholangiography (PTC)      │
│  ➤ If ERCP fails/inaccessible (altered anatomy, duodenal           │
│    obstruction, failed cannulation)                                │
│  ➤ External biliary drain placement                                │
│                                                                     │
│  THIRD-LINE: EUS-Guided Biliary Drainage                           │
│  ➤ Emerging technique if ERCP/PTC not feasible                     │
│                                                                     │
│  FOURTH-LINE: Surgical Drainage                                     │
│  ➤ Last resort; T-tube, choledochotomy                             │
│  ➤ High morbidity/mortality in acute setting                       │
└────────────────────────────────────────────────────────────────────┘

Initial Resuscitation

Sepsis-6 Bundle (to be completed within 1 hour): [12,17]

Additional Resuscitation Measures:

• Correct coagulopathy with vitamin K (IV 10mg) and consider FFP if bleeding or urgent procedure
• Vasopressors (noradrenaline first-line) if hypotension persists despite fluid resuscitation
• Central venous access for monitoring and vasopressor administration if Grade III

Antibiotic Therapy

Empirical Antibiotic Regimens

FIRST-LINE OPTIONS: [14,18]

SEVERE/GRADE III or HEALTHCARE-ASSOCIATED:

PENICILLIN ALLERGY:

Antibiotic Duration

De-escalation

• Review blood/bile culture results at 48-72 hours
• Narrow spectrum based on sensitivities
• Consider IV-to-oral switch when clinically stable, tolerating oral intake, and no ongoing sepsis
• Oral options: Ciprofloxacin 500mg BD + Metronidazole 400mg TDS; Amoxicillin-Clavulanate 625mg TDS

Biliary Drainage

ERCP (Endoscopic Retrograde Cholangiopancreatography)

First-line drainage modality with 90-95% success rate: [8,9]

Contraindications to ERCP:

• Absolute: Duodenal obstruction, significant coagulopathy (unless corrected)
• Relative: Altered anatomy (Roux-en-Y, Billroth II—may need device-assisted ERCP)

Complications of ERCP:

• Post-ERCP pancreatitis (3-5%): Risk reduced by rectal NSAIDs, pancreatic stent
• Bleeding (1-2%): Usually post-sphincterotomy; managed endoscopically
• Perforation (less than 1%): May require surgical repair
• Cholangitis (1-3%): Paradoxically, incomplete drainage can worsen infection

Percutaneous Transhepatic Cholangiography (PTC)

Second-line when ERCP fails or is inaccessible: [10]

Procedure:

• Ultrasound/fluoroscopy-guided puncture of intrahepatic bile duct
• External drain placement for decompression
• May be internalised to stent later

Success rate: 80-90% Complications: Bleeding (2-5%), bile leak (2-3%), sepsis, catheter dislodgement

EUS-Guided Biliary Drainage

Emerging technique for failed ERCP/PTC: [19]

Success rate: 80-90% in expert centres Complications: Similar to ERCP plus peritonitis risk

Surgical Drainage

Last resort with high morbidity in acute setting:

Mortality: Significantly higher (10-20%) compared to endoscopic/percutaneous approaches in acute cholangitis

Drainage Timing by Severity

Supportive Care

Definitive Management of Underlying Cause

After acute episode resolution:

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10. Complications

Early Complications

Late Complications

Mortality Predictors

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11. Prognosis and Outcomes

Mortality Rates

Prognostic Factors

Long-Term Outcomes

Timing of Cholecystectomy

For patients with choledocholithiasis: [20]

• Index admission cholecystectomy (within same hospital stay) reduces recurrent biliary events
• Early cholecystectomy (within 2 weeks) preferred over delayed (6+ weeks)
• Reduces risk of recurrent cholangitis, pancreatitis, and cholecystitis

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12. Prevention and Screening

Primary Prevention

Secondary Prevention

Post-ERCP Cholangitis Prevention

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13. Evidence and Guidelines

Key Guidelines

Landmark Studies and Evidence

Tokyo Guidelines Development and Validation: [1,7]

• Established internationally accepted diagnostic criteria and severity grading
• TG18/TG21 updates refined criteria based on validation studies
• Improved outcomes when guidelines followed (reduced mortality, LOS)

Early vs Delayed Drainage: [9]

• Systematic reviews demonstrate reduced morbidity with early biliary drainage
• Severe cholangitis: drainage within 24 hours improves survival
• Moderate cholangitis: drainage within 48 hours recommended

ERCP vs Conservative Management:

• Historical studies showed > 50% mortality with antibiotics alone
• ERCP reduced mortality to less than 10% in non-severe cases
• Emergency ERCP for severe cholangitis is now standard of care

Antibiotic Duration: [18]

• Short-course (4-7 days) antibiotics adequate with successful source control
• Non-inferior to longer courses in terms of clinical cure
• Reduces antibiotic resistance and adverse effects

Level of Evidence Summary

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14. Patient and Layperson Explanation

What is Acute Cholangitis?

Acute cholangitis is a serious infection of the bile ducts—the tubes that carry bile from your liver to your intestine. It usually happens when something blocks the bile duct (most commonly a gallstone), which allows bacteria to build up and cause infection.

What Causes It?

The most common cause is a gallstone that has moved from the gallbladder into the main bile duct and become stuck. Other causes include:

• Narrowing of the bile duct (strictures)
• Blockage from cancer
• Problems with tubes (stents) placed in the bile duct
• Parasites (in some parts of the world)

What Are the Symptoms?

The classic symptoms are:

1. High fever with shaking chills (rigors)
2. Pain in the upper right side of your tummy (under the ribs)
3. Yellow skin and eyes (jaundice)

In severe cases, you may also develop:

• Low blood pressure (feeling faint or dizzy)
• Confusion

If you have these severe symptoms, call emergency services immediately—this is a medical emergency.

How Is It Diagnosed?

Doctors will:

• Take blood tests to check for infection and liver function
• Perform an ultrasound scan of your tummy
• Sometimes do a CT scan or MRI
• Take blood samples to find what bacteria is causing the infection

How Is It Treated?

Cholangitis requires urgent treatment in hospital:

1. Fluids through a drip to support your blood pressure
2. Strong antibiotics through a drip to fight the infection
3. A procedure to clear the blockage—usually an ERCP (endoscopic retrograde cholangiopancreatography):
   • A flexible camera is passed through your mouth into your stomach and intestine
   • Special instruments are used to remove stones or place a tube (stent) to drain bile
4. Intensive care if you are very unwell

What Happens If It's Not Treated?

Without prompt treatment, the infection can spread to your bloodstream (sepsis), cause organ failure, and be life-threatening. However, with early treatment, most people recover well.

Recovery and Follow-Up

After treatment for cholangitis:

• You will usually stay in hospital for several days
• If gallstones caused the problem, you may need surgery to remove your gallbladder (cholecystectomy) during the same admission or within a few weeks
• If you have a stent, it may need to be changed every few months

When to Seek Help

See a doctor urgently if you have:

• Fever with yellowing of your skin or eyes
• Severe upper abdominal pain
• Shaking chills
• Confusion or feeling very unwell

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15. Examination Focus

High-Yield Exam Topics

Sample Viva Questions and Model Answers

Q1: A 68-year-old woman presents with fever, jaundice, and right upper quadrant pain. How would you manage her?

Model Answer:

"This presentation describes Charcot's triad, which is highly suggestive of acute cholangitis. My immediate priorities are resuscitation and establishing the diagnosis and severity.

Initial management (Sepsis-6 bundle):

• High-flow oxygen targeting SpO2 94-98%
• IV access and take blood cultures (2 sets before antibiotics)
• Commence IV broad-spectrum antibiotics within 1 hour—I would give piperacillin-tazobactam 4.5g IV or ceftriaxone 2g with metronidazole 500mg
• IV crystalloid fluid bolus if hypotensive or lactate elevated
• Check serum lactate
• Monitor urine output; catheterise if oliguric

Investigations:

• Bloods: FBC, CRP, LFTs, amylase, coagulation, renal function, lactate
• Blood cultures x2
• Urgent abdominal ultrasound looking for CBD dilatation and stones

Severity grading using Tokyo Guidelines (TG18):

• Assess for organ dysfunction (Grade III markers)
• Grade I = mild; Grade II = moderate; Grade III = severe

Definitive management:

• Urgent referral to gastroenterology/GI surgery for biliary drainage
• ERCP is first-line, with timing dependent on severity:
  • "Grade III: within 24 hours (ideally within 12 hours)"
  • "Grade II: within 24-48 hours"
  • "Grade I: semi-elective"
• If ERCP fails or is contraindicated, percutaneous transhepatic cholangiography (PTC) is the alternative
• ICU admission if Grade III with organ support as required

Follow-up:

• Once stabilised, cholecystectomy (if gallstone cause) during same admission or within 2 weeks to prevent recurrence"

Q2: What are the Tokyo Guidelines for acute cholangitis?

Model Answer:

"The Tokyo Guidelines (TG18/TG21) are internationally accepted criteria for the diagnosis, severity grading, and management of acute cholangitis.

Diagnosis requires:

1. Systemic inflammation: Fever > 38°C OR shaking chills OR laboratory evidence (WCC abnormal, CRP elevated)
2. Cholestasis: Jaundice OR abnormal LFTs (bilirubin, ALP, GGT elevated)
3. Imaging: Biliary dilatation OR evidence of aetiology (stone, stricture, stent)

• Definite diagnosis: All 3 categories
• Suspected diagnosis: Any 2 categories

Severity Grading:

Grade I (Mild):

• Does not meet Grade II or III criteria
• Responds to initial treatment
• Management: Antibiotics, semi-elective drainage

Grade II (Moderate):

• Any 2 of: WCC > 12,000 or less than 4,000; Fever > 39°C; Age ≥75; Bilirubin ≥5 mg/dL; Low albumin
• Does not have organ dysfunction
• Management: Early drainage within 24-48 hours

Grade III (Severe):

• Any organ dysfunction:
  • "Cardiovascular: Hypotension requiring vasopressors"
  • "Neurological: Altered consciousness"
  • "Respiratory: PaO2/FiO2 less than 300"
  • "Renal: Creatinine > 2 mg/dL"
  • "Hepatic: INR > 1.5"
  • "Haematological: Platelets less than 100,000"
• Management: ICU admission, urgent drainage within 24 hours (ideally 12 hours)

The guidelines have been validated and shown to improve outcomes when followed."

Q3: When would you consider PTC instead of ERCP?

Model Answer:

"Percutaneous Transhepatic Cholangiography (PTC) is considered when ERCP is unsuccessful or technically not feasible.

Indications for PTC:

1. Failed ERCP cannulation (occurs in 5-10% of cases)
2. Altered surgical anatomy preventing endoscopic access:
   • Roux-en-Y gastric bypass or hepaticojejunostomy
   • Whipple procedure (pancreaticoduodenectomy)
   • Billroth II gastrectomy (can attempt device-assisted ERCP first)
3. Duodenal obstruction:
   • Tumour infiltration
   • Severe duodenal stenosis
4. Hilar biliary obstruction:
   • Klatskin tumour—PTC may provide better access to intrahepatic ducts
5. Patient factors:
   • Too unstable for prolonged endoscopy
   • Contraindication to sedation/general anaesthesia

Procedure:

• Performed by interventional radiology
• Ultrasound or fluoroscopy-guided puncture of dilated intrahepatic bile duct
• Placement of external biliary drain for decompression
• Can be converted to internal-external drain or stent later

Success rate: 80-90%

Complications:

• Bleeding (2-5%)
• Bile leak and biliary peritonitis (2-3%)
• Sepsis
• Catheter dislodgement
• Pleural complications if right-sided approach

PTC is complementary to ERCP, and having access to both techniques is essential for comprehensive management of biliary disease."

Common Exam Errors

Clinical Pearls for Examiners

1. "Cholangitis without jaundice": Can occur early or in partial obstruction; high index of suspicion required

2. "The stone may have passed": CBD may not be dilated if stone recently passed; LFTs may still be deranged

3. "Elderly may present atypically": Confusion, falls, or general deterioration without classic triad

4. "Post-ERCP fever": Distinguish post-procedural bacteraemia from unsuccessful drainage or pancreatitis

5. "Malignant cholangitis has worse outcomes": Higher mortality, often requires metal stent, may need repeated interventions

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16. References

1. Miura F, Okamoto K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):17-30. doi:10.1002/jhbp.512 [PMID: 29032610]

2. Lee JG. Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol. 2009;6(9):533-541. doi:10.1038/nrgastro.2009.126 [PMID: 19652653]

3. Kiriyama S, Takada T, Strasberg SM, et al. TG13 diagnostic criteria and severity grading of acute cholangitis. J Hepatobiliary Pancreat Sci. 2013;20(1):24-34. doi:10.1007/s00534-012-0561-3 [PMID: 23307001]

4. Reynolds BM, Dargan EL. Acute obstructive cholangitis; a distinct clinical syndrome. Ann Surg. 1959;150(2):299-303. doi:10.1097/00000658-195908000-00013 [PMID: 13670595]

5. Tazuma S, Unno M, Igarashi Y, et al. Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol. 2017;52(3):276-300. doi:10.1007/s00535-016-1289-7 [PMID: 27942871]

6. Attasaranya S, Fogel EL, Lehman GA. Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis. Med Clin North Am. 2008;92(4):925-960. doi:10.1016/j.mcna.2008.03.001 [PMID: 18570948]

7. Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2021;28(8):674-684. doi:10.1002/jhbp.877 [PMID: 34232559]

8. Lai EC, Mok FP, Tan ES, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med. 1992;326(24):1582-1586. doi:10.1056/NEJM199206113262401 [PMID: 1584258]

9. Tan M, Schaffalitzky de Muckadell OB, Laursen SB. Association between early ERCP and mortality in patients with acute cholangitis. Gastrointest Endosc. 2018;87(1):185-192. doi:10.1016/j.gie.2017.04.009 [PMID: 28433614]

10. Weber A, Gaa J, Rosca B, et al. Complications of percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts. Eur J Radiol. 2009;72(3):412-417. doi:10.1016/j.ejrad.2008.08.012 [PMID: 18842373]

11. Yeom DH, Oh HJ, Son YW, Kim TH. What are the risk factors for acute suppurative cholangitis caused by common bile duct stones? Gut Liver. 2010;4(3):363-367. doi:10.5009/gnl.2010.4.3.363 [PMID: 20981214]

12. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43(3):304-377. doi:10.1007/s00134-017-4683-6 [PMID: 28101605]

13. Melzer M, Toner R, Lacey S, Bettany E, Rait G. Biliary tract infection and bacteraemia: presentation, structural abnormalities, causative organisms and clinical outcomes. Postgrad Med J. 2007;83(986):773-776. doi:10.1136/pgmj.2007.064683 [PMID: 18057177]

14. Gomi H, Solomkin JS, Schlossberg D, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):3-16. doi:10.1002/jhbp.518 [PMID: 29090866]

15. Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 2007;102(8):1781-1788. doi:10.1111/j.1572-0241.2007.01279.x [PMID: 17509029]

16. Sung JY, Costerton JW, Shaffer EA. Defense system in the biliary tract against bacterial infection. Dig Dis Sci. 1992;37(5):689-696. doi:10.1007/BF01296423 [PMID: 1563308]

17. Daniels R, Nutbeam T, et al. The Sepsis Manual. 4th ed. UK Sepsis Trust. 2017.

18. van Lent AU, Bartelsman JF, Tytgat GN, Speelman P, Prins JM. Duration of antibiotic therapy for cholangitis after successful endoscopic drainage of the biliary tract. Gastrointest Endosc. 2002;55(4):518-522. doi:10.1067/mge.2002.122334 [PMID: 11923764]

19. Khan MA, Akbar A, Baron TH, et al. Endoscopic Ultrasound-Guided Biliary Drainage: A Systematic Review and Meta-Analysis. Dig Dis Sci. 2016;61(3):684-703. doi:10.1007/s10620-015-3933-0 [PMID: 26518134]

20. Friis C, Rothwell J, Weber DG, et al. Timing of cholecystectomy after endoscopic retrograde cholangiopancreatography for choledocholithiasis: A systematic review and meta-analysis. Surgery. 2023;173(2):368-380. doi:10.1016/j.surg.2022.09.028 [PMID: 36333170]

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Last Reviewed: 2026-01-09 | MedVellum Editorial Team

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