Acute Cholangitis
Summary
Acute cholangitis is a life-threatening bacterial infection of the biliary tree, usually secondary to biliary obstruction. The classic presentation is Charcot's triad (fever, right upper quadrant pain, jaundice), and severe cases manifest as Reynold's pentad (+ hypotension and altered mental status). The most common cause is choledocholithiasis (CBD stones); other causes include biliary strictures, malignancy, and ERCP complications. Without prompt treatment, acute cholangitis rapidly progresses to septic shock and multi-organ failure. Management requires early recognition, broad-spectrum antibiotics, resuscitation, and urgent biliary drainage — most commonly via ERCP. The Tokyo Guidelines (TG18) provide a standardised approach to diagnosis, severity grading, and management.
Key Facts
- Charcot's triad: Fever + RUQ pain + Jaundice (50-70% of cases)
- Reynold's pentad: Charcot's triad + Hypotension + Altered mental status (severe cholangitis)
- Common cause: Choledocholithiasis (~50-70%)
- Other causes: Biliary strictures, malignancy, stents, parasites
- Mortality: 5-10% overall; up to 30% if severe/not drained
- Organisms: E. coli, Klebsiella, Enterococcus, Pseudomonas, Bacteroides
- Diagnosis: Clinical + raised inflammatory markers + biliary dilatation on imaging
- Key treatment: Biliary drainage (ERCP preferred) + IV antibiotics
- Timing: Urgent ERCP within 24 hours for severe, 24-48 hours for moderate
- Tokyo Guidelines (TG18): Standardised grading and management
Clinical Pearls
"Charcot's Triad Is Only 50%": The classic triad is present in only 50-70% of cases. Have a high index of suspicion in any patient with unexplained sepsis, jaundice, or RUQ discomfort.
"Reynold's Pentad = Emergency": Hypotension and confusion added to Charcot's triad indicates severe cholangitis with high mortality. This requires immediate resuscitation and urgent biliary drainage.
"Stone Disease Dominates": CBD stones cause the majority of acute cholangitis. But always consider post-ERCP stent occlusion, strictures (benign or malignant), and parasites in endemic areas.
"Drain the Bile, Save the Life": Antibiotics alone won't cure acute cholangitis — the obstructed biliary system must be drained. ERCP is first-line; PTC if ERCP fails.
"TG18 Severity = Dictates Drainage Timing": Tokyo Guidelines Grade III (severe/organ dysfunction) requires drainage within 24 hours; Grade II (moderate) within 24-48 hours; Grade I (mild) can be semi-elective.
Why This Matters Clinically
Acute cholangitis is a medical emergency with significant mortality if not treated promptly. Early recognition, appropriate antibiotic therapy, and timely biliary drainage are life-saving. Every clinician should be able to recognise Charcot's triad and initiate the sepsis pathway while arranging urgent GI/surgical consultation.[1,2]
Incidence & Prevalence
| Parameter | Data |
|---|---|
| Incidence | ~1-2% of patients with choledocholithiasis develop cholangitis |
| Hospitalisation | Common cause of biliary emergency admission |
| Peak age | 50-70 years |
| Mortality | 5-10% overall; up to 30% in severe cases |
Demographics
| Factor | Details |
|---|---|
| Age | Increases with age; peak 6th-7th decade |
| Sex | Female predominance (gallstone disease) |
| Geography | Higher in regions with high gallstone prevalence |
| Post-ERCP | Common iatrogenic cause |
Risk Factors
| Factor | Notes |
|---|---|
| Cholelithiasis | Present in majority |
| Prior biliary surgery | Choledochojejunostomy, biliary stents |
| Biliary stent occlusion | Common in pancreatic/biliary malignancy |
| Strictures | Benign (primary sclerosing cholangitis) or malignant |
| ERCP | Iatrogenic cholangitis |
| Parasites | Ascaris, liver flukes (endemic areas) |
| Immunosuppression | Increased risk of severe infection |
Mechanism
Step 1: Biliary Obstruction
- Mechanical obstruction of the biliary tree (stones, stricture, tumour, stent)
- Increased intraductal pressure
- Bile stasis creates favourable environment for bacteria
Step 2: Bacterial Colonisation
- Bacteria ascend from duodenum via sphincter of Oddi
- Can also seed haematogenously or via portal vein
- Common organisms: E. coli (most common), Klebsiella, Enterococcus, Pseudomonas, Bacteroides
Step 3: Infection and Inflammation
- Multiplication of bacteria in obstructed bile
- Inflammatory response in bile duct wall
- Purulent bile (suppurative cholangitis in severe cases)
Step 4: Systemic Spread
- Elevated biliary pressure causes reflux into hepatic venules and lymphatics
- Bacteraemia and endotoxaemia
- Systemic inflammatory response syndrome (SIRS) → Sepsis
- Organ dysfunction (severe cholangitis)
Step 5: Multi-Organ Failure
- Septic shock if untreated
- Hepatic abscess formation
- ARDS, AKI, DIC
- Death
Common Organisms
| Organism | Frequency |
|---|---|
| Escherichia coli | 30-50% |
| Klebsiella spp. | 15-20% |
| Enterococcus spp. | 10-15% |
| Pseudomonas aeruginosa | 5-10% (post-procedure) |
| Bacteroides fragilis | 5-10% (anaerobic) |
| Enterobacter spp. | 5% |
Symptoms
| Symptom | Frequency | Notes |
|---|---|---|
| Fever with rigors | 80-90% | May be absent in elderly/immunosuppressed |
| Right upper quadrant pain | 60-70% | Biliary colic pattern |
| Jaundice | 60-70% | May be subtle initially |
| Nausea/vomiting | Common | Non-specific |
| Confusion | Severe cases | Reynold's pentad |
Signs
| Sign | Notes |
|---|---|
| Pyrexia (>38°C) | Often with rigors; high spiking fevers |
| RUQ tenderness | May have Murphy's sign |
| Jaundice | Scleral icterus |
| Hypotension | Severe (Reynold's pentad) |
| Tachycardia | Sepsis response |
| Altered mental status | Severe (encephalopathy from sepsis/hepatic failure) |
Charcot's Triad vs Reynold's Pentad
| Finding | Charcot's Triad | Reynold's Pentad |
|---|---|---|
| Fever | ✓ | ✓ |
| RUQ pain | ✓ | ✓ |
| Jaundice | ✓ | ✓ |
| Hypotension | — | ✓ |
| Altered mental status | — | ✓ |
| Significance | Classic presentation | Severe/suppurative cholangitis |
Red Flags
[!CAUTION] Red Flags — Severe Cholangitis (Tokyo Grade III):
- Cardiovascular dysfunction: Hypotension requiring vasopressors
- Neurological dysfunction: Altered consciousness
- Respiratory dysfunction: PaO2/FiO2 <300
- Renal dysfunction: Oliguria, creatinine >2 mg/dL
- Hepatic dysfunction: INR >1.5
- Haematological dysfunction: Platelets <100,000
Primary Assessment
General:
- Airway, Breathing, Circulation (sepsis assessment)
- Temperature, blood pressure, heart rate, respiratory rate, SpO2
- GCS/mental status
Abdominal Examination:
- RUQ tenderness
- Murphy's sign (may be positive)
- Hepatomegaly (if abscess)
- Signs of peritonism (if perforation — uncommon)
Skin:
- Jaundice (scleral icterus best assessed)
- Scratch marks (pruritus from cholestasis)
Severity Assessment (Tokyo Guidelines TG18)
| Grade | Criteria | Drainage Timing |
|---|---|---|
| Grade I (Mild) | Does not meet Grade II/III criteria | Semi-elective (when available) |
| Grade II (Moderate) | Any 2 of: WCC >12 or <4, Fever >39°C, Age ≥75, Bilirubin >5 mg/dL, Albumin <0.7×LLN | Within 24-48 hours |
| Grade III (Severe) | Organ dysfunction (CV, neuro, resp, renal, hepatic, haem) | Urgent (<24 hours); often ICU |
First-Line Investigations
| Investigation | Finding | Significance |
|---|---|---|
| FBC | Leukocytosis (or leukopenia in severe sepsis) | Infection |
| CRP/Procalcitonin | Elevated | Inflammatory marker |
| LFTs | Raised bilirubin (conjugated), ALP, GGT | Cholestasis pattern |
| Amylase/Lipase | May be mildly elevated | Rule out pancreatitis |
| Coagulation (INR, APTT) | Prolonged in severe/hepatic dysfunction | Vitamin K malabsorption; DIC |
| U&E, Creatinine | Elevated if renal dysfunction | Organ dysfunction |
| Lactate | Elevated | Tissue hypoperfusion |
| Blood cultures | Positive in 40-80% | Identifies organism; guide therapy |
Imaging
| Modality | Role | Findings |
|---|---|---|
| Abdominal USS | First-line | Dilated CBD (>6mm; >10mm post-cholecystectomy), gallstones, CBD stones (may not be seen) |
| CT Abdomen | If USS inconclusive or complications suspected | Biliary dilatation, level of obstruction, abscess, malignancy |
| MRCP | Non-invasive cholangiography | CBD stones, strictures, anatomy |
| ERCP | Diagnostic AND therapeutic | Stone extraction, stenting, sphincterotomy |
Tokyo Guidelines Diagnostic Criteria (TG18)
Systemic inflammation:
- Fever (>38°C) and/or rigors
- Lab evidence of inflammation (WCC, CRP elevated)
Cholestasis:
- Jaundice
- Abnormal LFTs (ALP, GGT, bilirubin)
Biliary imaging:
- Dilated bile duct and/or evidence of aetiology (stone, stricture, stent)
Diagnosis: Suspected if 1 systemic + 1 cholestasis OR 1 systemic + 1 imaging; Definite if systemic + cholestasis + imaging
Management Algorithm
ACUTE CHOLANGITIS
↓
┌──────────────────────────────────────────────────────────────┐
│ RESUSCITATION (SEPSIS-6) │
├──────────────────────────────────────────────────────────────┤
│ ➤ High-flow oxygen (target SpO2 >94%) │
│ ➤ Blood cultures (before antibiotics) │
│ ➤ IV broad-spectrum antibiotics (within 1 hour) │
│ ➤ IV fluid resuscitation (crystalloid, 20-30 mL/kg) │
│ ➤ Check lactate │
│ ➤ Monitor urine output (catheterise if severe) │
└──────────────────────────────────────────────────────────────┘
↓
┌──────────────────────────────────────────────────────────────┐
│ SEVERITY GRADING (TG18) │
├──────────────────────────────────────────────────────────────┤
│ Grade III (Severe): Any organ dysfunction → ICU; urgent │
│ Grade II (Moderate): Elevated markers → early drainage │
│ Grade I (Mild): Stable → semi-elective drainage │
└──────────────────────────────────────────────────────────────┘
↓
┌──────────────────────────────────────────────────────────────┐
│ BILIARY DRAINAGE │
├──────────────────────────────────────────────────────────────┤
│ ERCP (First-line): │
│ ➤ Sphincterotomy and stone extraction │
│ ➤ Stent insertion if complete clearance not possible │
│ ➤ Timing: Urgent (<24h) for Grade III; <24-48h for Grade II │
│ │
│ Percutaneous Transhepatic Cholangiography (PTC): │
│ ➤ If ERCP fails or inaccessible (e.g., altered anatomy) │
│ ➤ Insert drain to decompress biliary tree │
│ │
│ EUS-guided drainage: │
│ ➤ Emerging alternative if ERCP/PTC not feasible │
│ │
│ Surgical drainage: │
│ ➤ Last resort; high mortality in emergency setting │
│ ➤ Reserve for failed endoscopic/percutaneous approaches │
└──────────────────────────────────────────────────────────────┘
↓
┌──────────────────────────────────────────────────────────────┐
│ ANTIBIOTIC THERAPY │
├──────────────────────────────────────────────────────────────┤
│ EMPIRICAL (before culture results): │
│ ➤ Piperacillin-tazobactam 4.5g TDS IV │
│ OR │
│ ➤ Ceftriaxone 2g OD + Metronidazole 500mg TDS │
│ │
│ Duration: │
│ ➤ 4-7 days if source controlled (drainage successful) │
│ ➤ Longer if ongoing sepsis or inadequate drainage │
│ │
│ De-escalate based on culture and sensitivity │
└──────────────────────────────────────────────────────────────┘
Antibiotic Choices
| Regimen | Dose | Notes |
|---|---|---|
| Piperacillin-tazobactam | 4.5g TDS IV | Broad-spectrum; covers Gram-negatives, anaerobes |
| Ceftriaxone + Metronidazole | 2g OD + 500mg TDS | Alternative; good biliary penetration |
| Meropenem | 1g TDS IV | Reserved for severe/resistant organisms |
| Ciprofloxacin + Metronidazole | 400mg BD + 500mg TDS | If beta-lactam allergy |
Biliary Drainage Options
| Method | First/Second-Line | Success Rate | Notes |
|---|---|---|---|
| ERCP | First-line | 90-95% | Therapeutic; stone extraction; stent |
| PTC | Second-line | 80-90% | External drain; requires radiological expertise |
| EUS-guided drainage | Emerging | 80-85% | Alternative if ERCP fails |
| Surgical drainage | Last resort | Variable | High morbidity/mortality in acute setting |
Early Complications
| Complication | Management |
|---|---|
| Septic shock | ICU; vasopressors; aggressive resuscitation |
| Multi-organ failure | Organ support; prompt drainage |
| Hepatic abscess | Drainage (percutaneous or surgical) |
| Pancreatitis | Supportive; may complicate ERCP |
| Bleeding post-ERCP | Endoscopic haemostasis |
Late Complications
| Complication | Notes |
|---|---|
| Recurrent cholangitis | If stones not cleared; stricture not addressed |
| Secondary biliary cirrhosis | Chronic obstruction |
| Biliary stricture | Post-inflammatory; post-procedural |
Mortality
| Severity | Mortality |
|---|---|
| Mild (Grade I) | <1% |
| Moderate (Grade II) | 5% |
| Severe (Grade III) | 15-30% |
Prognostic Factors
| Good Prognosis | Poor Prognosis |
|---|---|
| Early presentation | Delayed presentation |
| Mild disease | Severe/Grade III |
| Successful early drainage | Failed/delayed drainage |
| No organ dysfunction | Multi-organ failure |
| Younger age | Elderly, comorbidities |
| Stone disease (treatable) | Malignant obstruction |
Key Guidelines
| Guideline | Organisation | Year | Key Points |
|---|---|---|---|
| Tokyo Guidelines (TG18) | Japanese Society of Hepato-Biliary-Pancreatic Surgery | 2018 | Diagnosis, severity, management algorithm |
| ESGE Guidelines | European Society of Gastrointestinal Endoscopy | 2019 | ERCP indications and techniques |
| NICE | National Institute for Health and Care Excellence | Various | Gallstone disease pathway |
Landmark Studies
Tokyo Guidelines Development (Miura et al. 2013; TG13, updated TG18)
- Standardised diagnostic criteria and severity grading
- Evidence-based management recommendations
- Improved outcomes when guidelines followed
- PMID: 23217645
Early vs Delayed ERCP (Tan et al. 2017, Cochrane)
- Systematic review supporting early biliary drainage
- Reduced morbidity with early intervention
- PMID: 28233886
Evidence Strength
| Intervention | Level | Evidence |
|---|---|---|
| Early ERCP for severe cholangitis | 1b | RCTs |
| Broad-spectrum antibiotics | 1a | Meta-analysis |
| Tokyo severity grading | 2a | Cohort/validation studies |
What is Acute Cholangitis?
Acute cholangitis is a serious infection of the bile ducts — the tubes that carry bile from the liver to the intestine. It usually happens when a gallstone blocks the bile duct, allowing bacteria to build up.
What are the symptoms?
Common symptoms include:
- High fever with shaking chills (rigors)
- Pain in the upper right abdomen (under the ribs)
- Yellow skin and eyes (jaundice)
In severe cases, low blood pressure and confusion can occur — this is a medical emergency.
How is it treated?
Cholangitis requires urgent treatment in hospital:
- Fluids and antibiotics through a drip
- Clearing the blockage — usually with a procedure called ERCP (a camera test that goes down your throat to the bile duct) to remove stones or insert a tube (stent) to drain the bile
- ICU care if very unwell
What happens without treatment?
Without prompt treatment, the infection can spread to the blood (sepsis), cause organ failure, and be life-threatening. Early treatment dramatically improves outcomes.
Recovery
Most people recover well with prompt treatment. You may need a follow-up procedure (laparoscopic cholecystectomy — keyhole surgery to remove the gallbladder) to prevent future episodes.
Guidelines
-
Miura F, Okamoto K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis. J Hepatobiliary Pancreat Sci. 2018;25(1):17-30. PMID: 29032636
-
Dumonceau JM, Tringali A, Papanikolaou IS, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2018;50(9):910-930. PMID: 30086596
Key Studies
- Tan M, Schaffalitzky de Muckadell OB, Laursen SB. Early versus delayed endoscopic retrograde cholangiopancreatography (ERCP) for clearance of bile duct stones in acute biliary pancreatitis. Cochrane Database Syst Rev. 2017;12:CD007003. PMID: 29251338
Reviews
-
Kochar B, Akshintala VS, Afghani E, et al. Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized controlled trials. Gastrointest Endosc. 2015;81(1):143-149. PMID: 25088919
-
NICE. Gallstone disease: diagnosis and management (CG188). 2014 (updated 2017). nice.org.uk
High-Yield Exam Topics
| Topic | Key Points |
|---|---|
| Charcot's triad | Fever + RUQ pain + Jaundice (only ~50% of cases) |
| Reynold's pentad | Charcot's + Hypotension + Confusion = severe/emergency |
| Common cause | Choledocholithiasis (~50-70%) |
| Tokyo severity | Grade I/II/III; determines drainage urgency |
| Management | Sepsis-6 + Antibiotics + ERCP drainage |
| First-line antibiotics | Piperacillin-tazobactam OR Ceftriaxone + Metronidazole |
Sample Viva Questions
Q1: A 65-year-old presents with fever, jaundice, and RUQ pain. How do you manage?
Model Answer: This presentation is Charcot's triad, highly suggestive of acute cholangitis. Initial management follows Sepsis-6: oxygen, blood cultures, IV antibiotics (piperacillin-tazobactam), IV fluids, lactate measurement, urine output monitoring. I would request bloods (FBC, LFTs, amylase, clotting, lactate) and USS abdomen to assess for biliary dilatation and stones. I would grade severity using Tokyo Guidelines (TG18). I would urgently discuss with gastroenterology/hepatobiliary team for ERCP. Timing: within 24 hours for severe (organ dysfunction), 24-48 hours for moderate. If ERCP unavailable or fails, PTC is an alternative.
Q2: What are the Tokyo Guidelines for acute cholangitis?
Model Answer: The Tokyo Guidelines (TG18) provide standardised criteria for diagnosis, severity grading, and management of acute cholangitis:
Diagnosis requires systemic inflammation (fever, raised WCC/CRP) + cholestasis (jaundice, raised LFTs) + imaging evidence (dilated ducts, aetiology seen).
Severity grading:
- Grade I (Mild): No organ dysfunction
- Grade II (Moderate): Any 2 of: WCC >12 or <4, fever >39°C, age ≥75, bilirubin >5 mg/dL, albumin low
- Grade III (Severe): Organ dysfunction (cardiovascular, neurological, respiratory, renal, hepatic, haematological)
Management: Resuscitation + antibiotics; biliary drainage timing depends on severity (urgent for Grade III, early for Grade II, semi-elective for Grade I).
Q3: When is ERCP indicated emergently?
Model Answer: Emergency/urgent ERCP (within 24 hours) is indicated for:
- Severe cholangitis (TG18 Grade III) with organ dysfunction
- Reynold's pentad (hypotension, altered consciousness)
- Failure to respond to initial resuscitation and antibiotics
- Evidence of suppurative cholangitis (pus in biliary tree)
- Choledocholithiasis with concomitant acute biliary pancreatitis (within 24 hours if cholangitis present)
The goal is to decompress the obstructed biliary system to control sepsis.
Common Exam Errors
| Error | Correct Approach |
|---|---|
| Relying on Charcot's triad for diagnosis | Triad present in only 50%; high index of suspicion needed |
| Delaying antibiotics for ERCP | Start antibiotics immediately; ERCP is for drainage, not antibiotic replacement |
| Not recognising Reynold's pentad | Hypotension + confusion = severe; requires urgent ERCP |
| Forgetting PTC as alternative | PTC if ERCP fails or inaccessible (prior Roux-en-Y, etc.) |
| Wrong antibiotic choice | Need Gram-negative and anaerobic cover (pip-taz or ceftriaxone + metro) |
Last Reviewed: 2025-12-24 | MedVellum Editorial Team
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.