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Cholangitis

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cholangitis AND treatment

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Tokyo Guidelines acute cholangitis diagnostic criteria initial management biliary drainage

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https://pubmed.ncbi.nlm.nih.gov/28941329

Acute cholangitis is a bacterial infection of the bile ducts, usually caused by bile-flow obstruction, most often a common bile duct stone. It can rapidly progress to sepsis and needs urgent hospital assessment.

Typical features

  • Fever or chills
  • Right-upper abdominal pain
  • Jaundice
This combination is Charcot triad. Confusion and low blood pressure added to the triad suggest severe sepsis, sometimes called Reynolds pentad.

Causes

  • Choledocholithiasis, the commonest cause
  • Benign biliary stricture
  • Pancreatic, biliary, or ampullary cancer
  • Blocked biliary stent
  • Less often, parasites or post-procedure obstruction

Diagnosis

Clinicians use:
  • CBC, liver tests, bilirubin, CRP, blood cultures
  • Ultrasound first line to look for duct dilation and gallstones
  • CT or MRCP if needed
  • ERCP when drainage and treatment are needed
Tokyo diagnostic criteria combine systemic inflammation, cholestasis, and imaging evidence of biliary obstruction or dilation.

Treatment

  1. Immediate resuscitation: IV fluids, monitoring, analgesia, correction of electrolytes.
  2. IV antibiotics: chosen according to severity, likely organisms, prior biliary procedures, local resistance, and renal function.
  3. Biliary decompression: usually ERCP with drainage, stone extraction, and/or stenting. This is the definitive urgent step when disease is moderate, severe, or not responding to initial therapy. Percutaneous drainage or surgery may be used when ERCP is not feasible.
The Tokyo Guidelines management paper recommends antibiotics and supportive care for all patients, early drainage for moderate illness, and urgent drainage plus organ support for severe illness.

Severity

  • Mild: responds to initial medical therapy.
  • Moderate: needs early bile-duct drainage.
  • Severe: organ dysfunction, such as shock, altered consciousness, hypoxemia, acute kidney injury, coagulopathy, or thrombocytopenia. Requires ICU-level care and urgent drainage.
Seek emergency care now for fever with jaundice or upper abdominal pain, particularly with low blood pressure, confusion, persistent vomiting, or reduced urine output.
Do not confuse this with primary biliary cholangitis, which is a chronic autoimmune disease of small intrahepatic bile ducts, not an acute bacterial emergency.
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