Acute Cholangitis

Biliary tract infection from obstruction + bacteria; requires urgent biliary drainage

Symptoms / Associated Sx

  • Charcot's triad: fever/rigors + RUQ pain + jaundice (present ~50–70%)

  • Reynolds' pentad (severe): Charcot's + hypotension + AMS → septic shock

  • Nausea, vomiting, scleral icterus, dark urine

  • Bacteremia (blood cultures positive in ~50%)

Denies

  • Peritoneal signs or rigidity (rules out perforation/peritonitis as primary)

  • Prior cholecystectomy without residual biliary anatomy (influences likelihood)

  • Fever without jaundice and RUQ pain (reduces classic cholangitis likelihood)

Social History (SHx)

Prior cholelithiasis, CBD stones, prior cholangitis, biliary stent (stent occlusion), prior ERCP, biliary-enteric anastomosis, PSC, malignancy.

Main Etiology

  • CBD stone (~85%), biliary stricture, biliary stent occlusion

  • Malignant biliary obstruction (pancreatic head cancer, cholangiocarcinoma)

  • Parasitic (Ascaris, liver flukes — endemic regions)

Most Common DDx

  • Acute cholecystitis (RUQ pain + fever; Murphy's sign; cystic duct obstruction; CBD typically not dilated; no jaundice unless Mirizzi; US — wall thickening + pericholecystic fluid)

  • Acute pancreatitis with biliary etiology (epigastric pain radiating to back; lipase >3× ULN; may coexist with cholangitis; CT/MRCP distinguishes)

  • Liver abscess (fever + RUQ pain; elevated LFTs; CT shows hypodense collection in liver parenchyma; usually no jaundice unless obstructing)

  • Ascending UTI / urosepsis (fever + chills; no jaundice; RUQ not tender; UA positive; urine culture positive)

  • Hepatitis — viral or alcoholic (elevated transaminases >> ALP; jaundice present; no CBD dilation; no stones)

  • Right-sided pneumonia (RUQ pain from diaphragmatic irritation; fever; CXR consolidation; no CBD dilation; lipase normal)

DATA

  • CBC (WBC >12k), CMP (bilirubin, ALP, GGT, creatinine), PT/INR

  • Blood cultures × 2, lactate, UA/urine culture

  • RUQ ultrasound (CBD dilation + stones); CT abdomen; MRCP; ERCP (diagnostic + therapeutic)

Home Meds

  • Anticoagulants (hold; reverse if INR >1.5 and urgent ERCP needed)

  • Prior antibiotic exposure (note — guides empiric choice)

Plan

  • Antibiotics (start immediately):

    • Mild-Moderate (TG I–II): Piperacillin-tazobactam 3.375 g IV q6h; alternative: Ceftriaxone 2 g IV daily + Metronidazole 500 mg IV q8h

    • Severe (TG III) / healthcare-associated: Meropenem 1 g IV q8h ± Vancomycin if MRSA risk

    • Duration: 4–7 days IV → step-down to PO when tolerating and clinically improved

  • Biliary drainage (ERCP) — mandatory:

    • TG I: within 72h; TG II: within 24–48h; TG III: emergent within 24h

    • ERCP: sphincterotomy + stone extraction + biliary stent if needed

    • If ERCP fails: PTBD or EUS-guided biliary drainage

  • IV fluid resuscitation (LR/NS); vasopressors (norepinephrine) if septic shock → ICU

  • Cholecystectomy after recovery (gallstone etiology — within 2–6 weeks)

  • Blood cultures × 2 before antibiotics; narrow at 48–72h per sensitivities

  • Daily CBC, CMP, LFTs, lactate; trend fever curve; GI + surgery consult; IR if ERCP not feasible; PT/OT

  • Discharge: Complete antibiotic course (5–7 days total); cholecystectomy scheduling; biliary stent exchange in 3 months if placed; hepatology/oncology if malignant obstruction; LFTs recheck 2 weeks

Red Flags

  • Reynolds' pentad → septic shock → ICU + emergent ERCP within 24h

  • Lactate >4 or septic shock → aggressive resuscitation + vasopressors; biliary decompression is source control

  • ERCP failure → PTBD or EUS-guided biliary drainage immediately

  • Persistent fever/bacteremia after drainage → retained stone, stent occlusion, liver abscess → CT + repeat ERCP

  • Cholangitis in PSC → high-grade stricture or cholangiocarcinoma must be excluded

Senior IM Resident Pearls

  • Tokyo Guidelines 2018 (TG18): Grade I = mild (antibiotics alone); Grade II = moderate (urgent ERCP); Grade III = severe (emergent ERCP/ICU)

  • Charcot's triad only ~50–70% sensitive — absence does not rule out cholangitis; CBD dilation + elevated LFTs + clinical context should prompt treatment

  • Most common organisms: E. coli, Klebsiella, Enterococcus; anaerobes if enteric anastomosis or stent

  • Common mistake: Delaying antibiotics while awaiting ERCP — start antibiotics immediately; ERCP is source control, not a substitute

  • Common mistake: Not drawing blood cultures before antibiotics — bacteremia in ~50%; guides narrowing

ORDERS

Labs

Admission Labs

  • CBC with diff

  • CMP

  • BMP

  • LFTs (AST, ALT, ALP, GGT, total/direct bilirubin)

  • PT/INR

  • PTT

  • Lactate

  • Magnesium

  • Phosphorus

Sepsis Workup

  • Blood cultures ×2 (before antibiotics)

  • UA

  • Urine culture

Additional Labs

  • Lipase (gallstone pancreatitis)

  • Amylase

  • Type & Screen if unstable

  • Procalcitonin (optional)

Trending Labs

  • CBC daily

  • CMP daily

  • LFTs daily

  • BMP daily

  • Lactate q4–6 hr if septic

  • Blood culture results

Imaging

First-Line

RUQ Ultrasound

Evaluate:

  • CBD dilation

  • Gallstones

  • Cholecystitis

  • Biliary obstruction

Additional Imaging

MRCP

If:

  • Diagnosis uncertain

  • Stable patient

  • ERCP not immediately needed

CT Abdomen/Pelvis

If:

  • Liver abscess

  • Malignancy

  • Complication

  • Persistent bacteremia

Procedures

Source Control (Mandatory)

ERCP

Timing

Tokyo Grade I (Mild)

  • ERCP within 72 hr

Tokyo Grade II (Moderate)

  • ERCP within 24–48 hr

Tokyo Grade III (Severe)

  • Emergent ERCP within 24 hr

During ERCP

  • Sphincterotomy

  • Stone extraction

  • Biliary stent placement

  • Biliary decompression

If ERCP Fails

PTBD

(Percutaneous Transhepatic Biliary Drainage)

OR

EUS-guided Biliary Drainage

After Recovery

Cholecystectomy

  • Same admission if feasible
    OR

  • Within 2–6 weeks

Medications

Antibiotics (Start Immediately)

Mild–Moderate Cholangitis

Piperacillin-Tazobactam

  • 4.5 g IV q6h

OR

Ceftriaxone

  • 2 g IV daily

PLUS

Metronidazole

  • 500 mg IV q8h

Severe Cholangitis (TG III)

Meropenem

  • 1 g IV q8h

Add Vancomycin If

  • MRSA risk

  • Prior resistant infection

Vancomycin

  • 15–20 mg/kg IV q8–12h

Step-Down Oral Therapy

Amoxicillin-Clavulanate

  • 875 mg PO BID

OR

Ciprofloxacin

  • 500–750 mg PO BID

PLUS

Metronidazole

  • 500 mg PO TID

Duration

  • Total 4–7 days after adequate drainage

Fluid Resuscitation

LR Preferred

  • 30 mL/kg bolus if septic

Then:

  • Maintenance fluids

Septic Shock

Norepinephrine

  • First-line vasopressor

ICU Admission

Pain Control

Mild–Moderate

  • Acetaminophen 650 mg PO q6h PRN
    (max 2 g/day if liver disease)

Severe

  • Hydromorphone 0.2–0.5 mg IV q2–4h PRN

Antiemetics

Ondansetron

  • 4 mg IV q6h PRN

Hold Medications

Before ERCP

  • Warfarin

  • DOACs

  • Heparin

  • Clopidogrel

  • Ticagrelor

Goal

  • INR <1.5

Consults

Gastroenterology (STAT)

  • ERCP

General Surgery

  • Cholecystectomy planning

Interventional Radiology

  • Failed ERCP

  • PTBD

ICU

If:

  • Septic shock

  • Vasopressors

  • Reynolds pentad

Oncology

If:

  • Pancreatic cancer

  • Cholangiocarcinoma

  • Malignant obstruction

Infectious Disease

  • MDR organisms

  • Persistent bacteremia

PT/OT

  • Deconditioning

Nursing Orders

Monitoring

  • Telemetry

  • Vital signs q4 hr

  • Strict I&O

  • Daily weights

Diet

  • NPO pending ERCP

Notify Physician Immediately

  • Fever

  • Hypotension

  • AMS

  • Worsening jaundice

  • Increasing RUQ pain

Follow-Up Studies

Daily

  • CBC

  • CMP

  • LFTs

  • Bilirubin

Follow

  • Blood cultures

  • ERCP findings

  • MRCP findings

  • Pathology if obtained

After ERCP

  • Monitor bilirubin trend

  • Monitor lipase (post-ERCP pancreatitis)

Escalation Criteria

Reynolds Pentad

  • Fever

  • Jaundice

  • RUQ pain

  • Hypotension

  • AMS

→ ICU + Emergent ERCP

Septic Shock

  • Lactate >4

  • Vasopressor requirement

→ ICU

Persistent Bacteremia/Fever After ERCP

Consider:

  • Retained stone

  • Stent occlusion

  • Liver abscess

→ CT Abdomen/Pelvis + Repeat ERCP

Post-ERCP Pancreatitis

  • Lipase >3× ULN

  • Worsening pain

→ Aggressive LR hydration
→ Pain control