Acute (Ascending) Cholangitis ✅

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🚨 Acute (ascending) cholangitis is a syndrome of biliary obstruction plus infection that can rapidly progress to sepsis and organ dysfunction. 💡 The classic picture is Charcot’s triad: fever 🌡️ + jaundice 🟡 + right upper quadrant pain 🤕. ⚠️ Reynolds’ pentad suggests more severe disease: Charcot’s triad + hypotension 💉 + confusion 🧠. 👉 This is a medical emergency: start resuscitation and IV antibiotics early, but remember that source control with biliary drainage is often the lifesaving step. 🔧 In UK practice, ERCP is usually the preferred drainage method when feasible.

📌 About

• 🔥 Biliary obstruction raises intraductal pressure and promotes bacterial translocation into the bloodstream, leading to bacteraemia and sepsis.
• 🪨 The commonest cause is common bile duct stones.
• 📈 Risk is increased by older age, prior biliary disease, malignant obstruction, and previous biliary instrumentation such as ERCP or stenting.
• ⚠️ Untreated cholangitis can progress quickly to shock, multi-organ failure, and death.

🦠 Aetiology & Microbiology

• Common causes of obstruction:
  • 🪨 Gallstones
  • 🧬 Malignancy (for example cholangiocarcinoma or pancreatic cancer)
  • 🧵 Benign strictures, including post-operative strictures or PSC-related disease
  • 🪱 Parasites in endemic areas (rare in the UK)
• Typical organisms:
  • Gram-negative enteric organisms such as E. coli, Klebsiella, and Enterobacter
  • Gram-positive organisms including Enterococcus and Streptococcus
  • ⚠️ Infection is often polymicrobial

📊 Clinical Features

• 🌡️ Fever, rigors, or both
• 🤕 Right upper quadrant or upper abdominal pain
• 🟡 Jaundice
• ⚡ Features of sepsis: tachycardia, hypotension, tachypnoea, delirium, reduced urine output
• 🧻 Cholestatic symptoms may include dark urine, pale stools, and pruritus

Exam pearl: Charcot’s triad is useful but not sensitive enough to rule cholangitis in or out on its own. That is why the Tokyo criteria combine systemic inflammation, cholestasis, and imaging evidence of obstruction.

🔎 Diagnosis (Tokyo Guidelines 2018)

• A. Systemic inflammation: fever/rigors or raised inflammatory markers such as WCC/CRP
• B. Cholestasis: jaundice or abnormal cholestatic liver tests
• C. Imaging: biliary dilatation or evidence of an obstructing lesion

• ✅ Suspected cholangitis: A + (B or C)
• ✅ Definite cholangitis: A + B + C

🚦 Severity (Tokyo Guidelines 2018)

• 🟥 Severe (Grade III): organ dysfunction such as cardiovascular, neurological, respiratory, renal, hepatic, or haematological failure → urgent biliary drainage as soon as possible
• 🟧 Moderate (Grade II): more severe inflammatory illness or poor physiological reserve → early biliary drainage
• 🟩 Mild (Grade I): no organ dysfunction and not meeting Grade II criteria → antibiotics and supportive care may stabilise initially, but ongoing obstruction often still needs definitive treatment

🧪 Investigations

• 🩸 Bloods: FBC, U&E, creatinine, CRP, LFTs, bilirubin, clotting, lactate
• 🧫 Blood cultures: ideally before antibiotics if this does not delay treatment
• 🖥️ Ultrasound: usually the first imaging test in UK practice to look for duct dilatation, gallstones, and gallbladder pathology
• 🧲 MRCP: useful if the diagnosis or level of obstruction is uncertain and the patient is stable enough for further imaging
• 📡 CT: useful if complications, malignancy, or an alternative diagnosis is suspected
• 🔧 ERCP: mainly a therapeutic procedure rather than a first-line diagnostic test

⚠️ Complications

• 🦠 Sepsis and septic shock
• 🫀 Multi-organ dysfunction including AKI
• 🧠 Delirium or encephalopathy
• 🧫 Hepatic abscess
• ⏳ Recurrent cholangitis and chronic biliary injury if the underlying obstruction is not definitively managed

💊 Management (UK practice + Tokyo Guidelines)

1. 🆘 Immediate resuscitation
   • 💉 Give IV fluids as needed, oxygen if required, and measure lactate
   • 📟 Use NEWS2 / physiological monitoring and escalate early if the patient is septic or deteriorating
   • 🧫 Take blood cultures before antibiotics if feasible without delaying treatment
2. 💊 Start empirical IV antibiotics early
   • Give broad-spectrum IV antibiotics according to local microbiology policy
   • Common UK regimens may include piperacillin–tazobactam or equivalent broad-spectrum cover, depending on severity and local resistance patterns
   • Tailor therapy to blood cultures, biliary source, and local guidance
3. 🔧 Source control = biliary decompression
   • 🥇 ERCP is usually first choice for drainage and may allow sphincterotomy, stone extraction, and/or stent insertion
   • 🩺 Percutaneous transhepatic biliary drainage is an alternative if ERCP is not possible or unsuccessful
   • ⚠️ Severe cholangitis: urgent drainage as soon as possible
   • ⚠️ Moderate cholangitis: early drainage is usually recommended
4. 🔪 Definitive prevention
   • If gallstones are the cause, plan definitive stone management and usually laparoscopic cholecystectomy once the patient has recovered
5. 🤝 Supportive and specialist care
   • Involve gastroenterology / HPB surgery / interventional radiology early
   • Consider critical care if there is organ dysfunction or shock

💡 Clinical Pearls

• 🚨 In an unwell jaundiced patient with cholestatic LFTs, think cholangitis early.
• 🧠 Antibiotics help, but drainage is often the decisive treatment because the infection is being driven by obstruction and pressure.
• ⚠️ Older patients may present atypically with delirium or sepsis and less obvious pain.
• 📉 Delay in source control is associated with worse outcomes.
• 📝 In exams and practice, a safe summary is: resuscitate, culture, start IV antibiotics, and arrange urgent biliary drainage.

📚 References

• NICE CG188 – Gallstone disease: diagnosis and management.
• NICE NG253 – Suspected sepsis in people aged 16 or over: recognition, diagnosis and early management.
• Tokyo Guidelines 2018 – diagnostic criteria, severity grading, and initial management of acute cholangitis.
• NICE QS104 – urgent ERCP within 72 hours for common bile duct stones causing jaundice.

Teaching Commentary 🧑‍⚕️

Ascending cholangitis is best understood as a pressure-driven infection. Obstruction raises biliary pressure, impairs bile flow, and allows bacteria to translocate into the bloodstream, so the patient can become septic quickly. That is why the management is not just “treat the infection” but “treat the infection and relieve the obstruction.” The Tokyo criteria are helpful because they formalise a syndrome clinicians often recognise intuitively: inflammation + cholestasis + obstructed ducts. In UK practice, the safest bedside mindset is to combine sepsis recognition with early specialist escalation for ERCP or drainage.