Acute Cholangitis 

1. Definition

Acute cholangitis is a life-threatening ascending infection of the biliary tree occurring due to biliary obstruction + bacterial infection.

Classic triad = Charcot’s triad

• Fever
• Jaundice
• Right upper quadrant pain

Severe disease = Reynolds pentad

• Charcot triad
• Hypotension
• Altered mental status

Charcot triad present in ~50–70% only → absence does NOT exclude cholangitis.

2. Pathophysiology

Mechanism

1. Obstruction of bile duct
• Stone (most common)
• Tumour
• Stricture
• Stent blockage

2. → ↑ Intraductal pressure (>20 cm H₂O)
3. → Breakdown of tight junctions
4. → Bacteriobilia → Bacteraemia
5. → Sepsis / Septic shock

3. Causes of Biliary Obstruction

4. Microbiology 

Most common organisms

• E. coli (most common)
• Klebsiella
• Enterococcus
• Enterobacter
• Anaerobes (less common)

 Infection is usually polymicrobial.

5. Clinical Features

 Early disease

• Fever with rigors(Infection)
• RUQ pain(Obstruction)
• Jaundice(Cholestasis)
• Nausea/vomiting

 Severe disease

• Hypotension(Sepsis)
• Confusion(Organ dysfunction)
• Oliguria
• Septic shock

6. Tokyo Guidelines 

Diagnosis requires:Diagnosis = A + B + C

A. Systemic inflammation

• Fever >38°C
• Raised WBC / CRP

B. Cholestasis

• Jaundice
• ↑ ALP / GGT / bilirubin

C. Imaging

• Dilated bile duct
• Cause of obstruction

7. Severity Grading (Tokyo Guidelines)

• Grade I (Mild)
• Grade II (Moderate)

Any 2:

• WBC >12,000 or <4,000
• Fever >39°C
• Age >75
• Hyperbilirubinaemia
• Low albumin

→ Early drainage (within 24–48 hrs)

 Grade III (Severe)

Organ dysfunction:

• Hypotension requiring vasopressors
• Altered mental state
• PaO₂/FiO₂ <300
• Creatinine >176 μmol/L
• INR >1.5
• Platelets <100

→ Requires urgent biliary drainage within 24 hours

8. Investigations

Bloods

• FBC → neutrophilia
• CRP ↑
• Bilirubin ↑
• ALP ↑
• GGT ↑
• ALT mild ↑
• Blood cultures (before antibiotics)

Imaging

Ultrasound (First-line)

Findings:

• Dilated CBD (>6 mm)
• Stone
• Gallbladder pathology

MRCP (Best non-invasive test)

• Defines level of obstruction
• No therapeutic role

ERCP (Gold standard – Diagnostic + Therapeutic)

• Stone extraction
• Stenting
• Drainage

9. Management 

Step 1 – Resuscitation

• ABC approach
• IV fluids
• Oxygen
• Blood cultures

Step 2 – IV Antibiotics (Immediately)

Empirical (UK practice):

• Piperacillin–tazobactam
  OR
• Ceftriaxone + metronidazole

Duration:

• 5–7 days (after source control)

Step 3 – Urgent Biliary Drainage

Preferred: ERCP

If ERCP fails:

• PTBD (percutaneous transhepatic drainage)
• Surgery (rare)

10. Complications

• Septic shock
• Liver abscess
• Acute kidney injury
• DIC
• Death (mortality up to 10–20%)

11. Differentials