AKT · Gastroenterology/Pancreatobiliary

Acute cholangitis

Infection of an obstructed biliary tree (CBD stone/stricture) — ascending cholangitis

Overview

Infection of an obstructed biliary tree (usually a common-bile-duct stone, also stricture/tumour/post-ERCP) — bile stasis + bacterial infection. Charcot's TRIAD: RUQ pain + fever/rigors + jaundice; Reynolds' PENTAD adds hypotension + confusion (suppurative cholangitis — septic shock). A medical emergency: resuscitate, IV antibiotics, and urgent biliary DECOMPRESSION (ERCP).

Recognise

CHARCOT triad: RUQ pain + FEVER/rigors + JAUNDICE; cholestatic LFTs (raised ALP/bilirubin/GGT)
REYNOLDS pentad (severe/suppurative): + hypotension + confusion → septic shock
Dilated CBD with a stone/stricture on imaging; older patients/known gallstones

Red flags

Septic shock/Reynolds pentad → emergency resuscitation + urgent biliary decompression
Acute kidney injury, organ dysfunction

Differentials & how to tell them apart

Acute cholecystitisfever + RUQ pain but NO jaundice, normal LFTs (cystic-duct) — cholangitis has jaundice + cholestatic LFTs (CBD)

Liver abscessswinging fever + liver collection on imaging

Acute pancreatitisraised amylase, epigastric-to-back pain

Viral hepatitishepatitic (ALT≫ALP) rather than obstructive pattern

Investigations

FBC/CRP (raised), LFTs (cholestatic), blood cultures, U&Es/lactate, clotting, amylase; ULTRASOUND (duct dilatation/stone); MRCP to define; ERCP is diagnostic and therapeutic.

Management

Resuscitate + IV antibiotics + urgent biliary decompression (ERCP)

1Resuscitate (sepsis six) and give IV broad-spectrum antibiotics. Confirm biliary obstruction (USS/MRCP) and arrange URGENT biliary decompression (ERCP).Gate: Antibiotics alone are not enough — an obstructed, infected biliary system needs DECOMPRESSION (ERCP); Reynolds pentad (hypotension + confusion) signals suppurative cholangitis/septic shock needing emergency drainage
2ERCP (sphincterotomy + stone extraction/stent); interval cholecystectomy for gallstone disease; PTC if ERCP not possible; treat malignant strictures.

Resuscitation + IV broad-spectrum antibiotics — sepsis management (cover Gram-negatives/anaerobes)

Urgent biliary DECOMPRESSION (ERCP) — the key intervention — drain the obstructed infected system (sphincterotomy + stone extraction/stent)

Percutaneous transhepatic drainage — if ERCP fails/unavailable

Key points

Charcot triad (RUQ pain + fever + jaundice) = cholangitis (CBD stone + infection) → antibiotics + ERCP decompression. Reynolds pentad = septic shock. Cholecystitis has the fever/pain but NO jaundice (cystic duct).

Monitor & prognosis

Sepsis/organ function; post-ERCP.

Good with prompt decompression; suppurative disease is high-mortality.

Source: Tokyo guidelines; BSG