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Cholangitis

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"cholangitis"[MeSH Terms] AND management

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Tokyo Guidelines 2018 acute cholangitis diagnostic criteria management biliary drainage

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Cholangitis is infection and inflammation of the bile ducts, most often acute ascending cholangitis caused by biliary obstruction, usually a common bile duct stone. Obstruction allows bacteria from the intestine to ascend into the biliary system, potentially causing sepsis.

Typical presentation

  • Fever or chills
  • Right upper abdominal pain
  • Jaundice
This is Charcot triad. Adding hypotension and confusion gives Reynolds pentad, suggesting severe sepsis.

Common causes

  • Common bile duct stones
  • Benign or malignant biliary strictures
  • Pancreatic, biliary, or hilar cancer
  • Blocked biliary stent
  • After ERCP or other biliary instrumentation

Diagnosis

Assessment includes vital signs, blood cultures before antibiotics when feasible, CBC, liver tests, renal function, coagulation studies, lactate, and imaging. Ultrasound is often first-line to look for biliary dilatation or gallstones; MRCP, CT, or ERCP may clarify the obstruction.
Tokyo diagnostic criteria combine:
  1. Systemic inflammation
  2. Cholestasis, such as jaundice or abnormal liver tests
  3. Imaging evidence of biliary obstruction or its cause

Treatment

Acute cholangitis can be life-threatening and generally requires hospital treatment:
  • IV fluids and sepsis management
  • Prompt broad-spectrum IV antibiotics
  • Biliary decompression, usually by ERCP with drainage, stone removal and/or stent placement
  • Percutaneous drainage or surgery if ERCP is not possible
Severity directs timing: mild disease may respond to antibiotics initially; moderate disease needs early drainage; severe disease with organ dysfunction needs resuscitation and urgent drainage. Mulholland and Greenfield’s Surgery, p. 470-471. The Tokyo Guidelines management flowchart likewise recommends early drainage for moderate disease and drainage as soon as feasible after stabilization in severe disease.

Seek emergency care now

Fever or shaking chills with jaundice, severe abdominal pain, confusion, low blood pressure, fainting, or reduced urine output needs emergency evaluation today.
Do not confuse acute cholangitis with:
  • Primary sclerosing cholangitis (PSC): chronic immune-mediated fibro-inflammatory narrowing of bile ducts.
  • Primary biliary cholangitis (PBC): chronic autoimmune destruction of small intrahepatic ducts.
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