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 

 1. INITIAL APPROACH (FIRST 1–3 HOURS: “SEPSIS MINDSET”)

Acute cholangitis is a life-threatening biliary sepsis → treat like septic shock with source control urgency

 Immediate priorities

• Airway, Breathing, Circulation (ABC)
• Early recognition of sepsis / septic shock
• Initiate Sepsis bundle within 1 hour

 Hemodynamic Resuscitation

• IV crystalloids (balanced preferred)
• 30 mL/kg in hypotension or lactate ≥4 mmol/L
• Target:
• MAP ≥65 mmHg
• Urine output ≥0.5 mL/kg/hr

 Vasopressors (if fluid refractory)

• First-line: Noradrenaline
• Add:
• Vasopressin (if refractory)
• Adrenaline (second-line)

 2. ANTIBIOTIC THERAPY (START WITHIN 1 HOUR)

 Common organisms

• Gram-negative: E. coli, Klebsiella
• Gram-positive: Enterococcus
• Anaerobes (less common but important in severe disease)

 Empirical Antibiotics 

 Mild–Moderate (Community-acquired)

• Piperacillin–tazobactam
  OR
• Ceftriaxone + Metronidazole

 Severe / Healthcare-associated / ICU

• Meropenem / Imipenem-cilastatin
  ±
• Vancomycin (if Enterococcus/MRSA risk)

 Special Situations

• Post-ERCP → cover resistant organisms
• Biliary stents → polymicrobial
• Immunocompromised → broader coverage

 Duration

• 4–7 days after source control
• Longer if:
• Bacteremia
• Incomplete drainage

 3. DEFINITIVE MANAGEMENT = SOURCE CONTROL 

Antibiotics alone are NOT sufficient in most cases

ERCP (Endoscopic Retrograde Cholangiopancreatography) – GOLD STANDARD

Indications

• Moderate–severe cholangitis
• Persistent obstruction
• Failed conservative therapy

Procedures

• Sphincterotomy
• Stone extraction
• Stent placement

 PTBD (Percutaneous Transhepatic Biliary Drainage)

Indications

• Failed ERCP
• Altered anatomy (e.g., post-surgery)
• Critically ill (bedside option)

 Surgical Drainage

• Rare now
• Indications:
• ERCP/PTBD failure
• Complications (e.g., perforation)

 TIMING OF BILIARY DRAINAGE 

10. Complications

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

11. Differentials