Acute Cholangitis

  • CC: RUQ pain, fever, jaundice (Charcot triad)

  • PP: N/V, confusion, hypotension, dark urine, pale stools

  • PN: No lower abdominal pain/urinary symptoms

  • pertinent SHx: Gallstones, prior ERCP/stents, alcohol use

  • Etiology:

    • Ascending biliary infection due to biliary obstruction

    • Most commonly from choledocholithiasis (CBD stones)

    • Cholelithiasis (gallstones in gallbladder) can migrate into CBD causing choledocholithiasis → cholangitis

  • risk factors: Gallstones, biliary strictures/stents, malignancy, older age

  • initial DATA:

    • CBC↑

    • Bilirubin/ALK phos↑

    • AST/ALT↑

    • Lactate if septic

    • RUQ US: CBD dilation ± stones

  • pending DATA:

    • Blood cultures

    • MRCP/ERCP

  • MEDS:

    • Home medications

    • Anticoagulation status

    • Recent antibiotic exposure/immunosuppression

  • COURSE:

    • Monitor for septic shock, worsening obstruction, pancreatitis

Plan:

  • Antibiotics:

    • Piperacillin-tazobactam 4.5 g IV q6h

    • OR Ceftriaxone 2 g IV daily + Metronidazole 500 mg q8h

    • Severe/MDR risk:

      • Cefepime + Metronidazole ± Vancomycin

  • NPO

  • Aggressive IV fluids

  • Trend CBC/LFTs/bilirubin/lactate

  • Blood cultures before antibiotics if possible

  • GI consult urgently for ERCP/source control

  • ERCP for biliary decompression/stone removal

  • Surgery consult for interval cholecystectomy

  • Escalate ICU care if hypotension/septic shock

  • PO step-down:

    • Augmentin 875 mg PO BID

    • OR Ciprofloxacin 500 mg BID + Metronidazole 500 mg TID

  • Duration:

    • Typically 4–7 days after adequate source control/ERCP

Key Quick Pearls

  • Fever + RUQ pain + Murphy sign → think acute cholecystitis

  • Fever + RUQ pain + jaundice → think acute cholangitis

  • High bilirubin + cholestatic LFTs (↑ Alk Phos/GGT) + CBD dilation → worry about choledocholithiasis/cholangitis

  • Normal bilirubin with RUQ pain/Murphy sign favors cholecystitis

  • AMS + hypotension + jaundice = severe cholangitis/Reynolds pentad

  • Cholangitis is generally the more emergent/septic condition requiring urgent ERCP.