Key Facts

Acute cholangitis is a life-threatening biliary emergency requiring prompt recognition, antibiotics, and biliary drainage. Delay in treatment leads to sepsis, multi-organ failure, and death.

Epidemiology

Acute cholangitis accounts for ~1% of emergency hospital admissions for abdominal pain. Choledocholithiasis is the cause in >60%. Increasing incidence due to aging population and increased biliary interventions. Mortality has decreased from >50% historically to ~5-10% with modern management.

Aetiology

• Choledocholithiasis: most common cause (>60%)
• Benign biliary stricture: post-surgical, chronic pancreatitis, PSC
• Malignant obstruction: pancreatic cancer, cholangiocarcinoma, ampullary tumour
• Post-procedural: ERCP, biliary stent occlusion
• Parasitic: Clonorchis sinensis, Ascaris lumbricoides, Opisthorchis (endemic areas)
• Recurrent pyogenic cholangitis: Southeast Asian populations

Pathophysiology

Biliary obstruction causes bile stasis and increased intraductal pressure. Bacteria ascend from the duodenum (E. coli, Klebsiella, Enterococcus) or enter via the portal vein. When intraductal pressure exceeds 20 cmH₂O, cholangiovenous reflux occurs — bacteria and endotoxins enter the bloodstream → bacteraemia → sepsis → multi-organ dysfunction. The rapid progression from biliary infection to septic shock makes urgent drainage critical.

Charcot's Triad (~50-70%)

1. Fever with rigors (often spiking, high-grade)
2. Jaundice (conjugated hyperbilirubinaemia)
3. RUQ pain

Reynolds' Pentad (~5-10% — Severe Cholangitis)

1. Confusion/altered consciousness (septic encephalopathy)
2. Hypotension/shock

Other Features

• Dark urine, pale stools
• Pruritus
• Nausea, vomiting
• Previous history of gallstones, biliary surgery, ERCP/stents

Red Flags

• Sepsis (NEWS ≥5, qSOFA ≥2)
• Organ dysfunction (AKI, coagulopathy, altered consciousness)
• Failure to respond to antibiotics within 24-48 hours
• Known malignant biliary obstruction with fever (stent occlusion)

Bedside

• Observations: NEWS score, sepsis screening
• Examination: RUQ tenderness, jaundice, confusion

Bloods

• FBC: leucocytosis (often marked — WCC >15)
• CRP: significantly raised
• LFTs: obstructive pattern (raised ALP/GGT/bilirubin); ALT may be raised (cholestatic hepatitis)
• Amylase/lipase: exclude concurrent pancreatitis
• U&Es: AKI
• Coagulation (INR): may be deranged (sepsis, vitamin K malabsorption)
• Lactate: raised in severe sepsis
• Blood cultures: positive in ~50-70% — MUST be taken before antibiotics
• Procalcitonin: may help guide antibiotic duration

Imaging

• USS abdomen: first-line — dilated CBD (>6 mm, or >8 mm post-cholecystectomy), gallstones, may visualise CBD stone
• CT abdomen: if complications suspected or diagnostic uncertainty
• MRCP: if diagnostic uncertainty about CBD stone presence

Special Tests

• ERCP: diagnostic AND therapeutic — sphincterotomy, stone extraction, biliary stenting; gold standard intervention
• EUS: if ERCP technically difficult; highly sensitive for CBD stones
• PTC (percutaneous transhepatic cholangiography): if ERCP fails or inaccessible (e.g. Roux-en-Y anatomy)
• Bile culture: taken at ERCP for targeted antibiotics

Non-pharmacological

• Sepsis 6: IV fluids, blood cultures, IV antibiotics, lactate, urine output, oxygen
• NBM, IV fluids: aggressive resuscitation
• HDU/ICU: if severe (Grade III)

Pharmacological

• IV antibiotics (start immediately after blood cultures):
  • Piperacillin-tazobactam 4.5 g TDS (most common choice)
  • OR co-amoxiclav 1.2 g TDS + gentamicin (weight-based, monitor levels)
  • OR meropenem 1 g TDS if severe sepsis or penicillin allergy
  • Duration: typically 5-7 days (shorter if source controlled with drainage)
• Vitamin K 10 mg IV if INR raised (obstructive jaundice)

Surgical/Interventional

• ERCP: cornerstone of management
  • Severe (Grade III): urgent ERCP within 24 hours (or as soon as resuscitated)
  • Moderate (Grade II): ERCP within 24-48 hours
  • Mild (Grade I): ERCP within 48-72 hours (may respond to antibiotics alone initially)
  • Sphincterotomy + stone extraction ± temporary biliary stent
• PTC + external biliary drainage: if ERCP fails or not technically possible
• EUS-guided biliary drainage: emerging option if ERCP/PTC not feasible
• Cholecystectomy: after cholangitis resolution if gallstone aetiology; during index admission or within 2 weeks

Referral Criteria

• Emergency gastroenterology/surgical review
• Urgent ERCP (interventional endoscopist)
• ICU if organ failure
• Interventional radiology if ERCP fails
• HPB MDT if malignant cause

With prompt antibiotics and biliary drainage, mortality is 5-10%. Without drainage, mortality for severe cholangitis exceeds 50%. Grade III (severe) cholangitis with organ failure has highest mortality (~15-20% despite treatment). Recurrence rate for stone-related cholangitis is significant without cholecystectomy. Malignant cholangitis has a worse prognosis related to the underlying malignancy.

Tokyo Guidelines (TG18) Severity Grading

Biliary Drainage Options