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

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