Acute cholangitis
Acute cholangitis is a bacterial infection of an obstructed biliary tree, classically presenting as Charcot triad of fever, right upper quadrant pain, and jaundice and progressing to septic shock when drainage is delayed. Diagnosis follows the Tokyo Guidelines and severity grade, and treatment combines prompt broad-spectrum antibiotics with biliary drainage, most often by ERCP.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Definition: acute cholangitis is a bacterial infection of the biliary tree that develops behind an obstruction, where stagnant bile becomes infected and rising ductal pressure drives bacteria into the bloodstream.
- Epidemiology
Dominant cause: choledocholithiasis accounts for most community-acquired cases, arising when a gallstone passes from the gallbladder into the common bile duct.
- Risk factors
Choledocholithiasis and gallstone disease: the strongest risk factor, because a migrated common bile duct stone is the usual obstructing lesion.
- Pathophysiology
Obstruction is the initiating event: a stone, stricture, or tumor blocks the common bile duct and produces bile stasis.
- Clinical features
Charcot triad: fever with chills or rigors, RUQ pain, and jaundice, the classic and most specific combination.
- Differential diagnosis
Acute cholecystitis: RUQ pain, fever, and a positive Murphy sign, but jaundice and a marked alkaline phosphatase rise are uncommon because obstruction is at the cystic duct rather than the common bile duct (acute cholecystitis).
- Diagnosis
Establish with the Tokyo Guidelines (TG18) criteria across three domains, then classify certainty: a suspected diagnosis requires one item from A plus one item from either B or C, and a definite…
- Management
Resuscitate and treat sepsis first: aggressive IV crystalloid resuscitation, correction of coagulopathy, nil by mouth, and prompt broad-spectrum IV antibiotics, started within 1 hour when septic…
- Complications
Septic shock and multiorgan failure: the leading cause of death, correlating with Grade III severity and delayed drainage.
- Prognosis
Outlook is drainage-dependent: with prompt antibiotics and timely biliary decompression most patients recover fully, whereas delay allows progression to multiorgan failure and death.
- Prevention
Interval cholecystectomy: definitive prevention of recurrence after gallstone-related cholangitis.
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Acute cholecystitis
Acute cholecystitis is inflammation of the gallbladder from cystic duct obstruction, most often by a gallstone, presenting with RUQ pain lasting more than 6 hours, fever, and a positive Murphy sign. Diagnosis follows the Tokyo Guidelines TG18 criteria and severity grade, and treatment combines IV antibiotics with early laparoscopic cholecystectomy, or cholecystostomy in patients too unstable for surgery.
- Choledocholithiasis
Choledocholithiasis is a gallstone that has migrated into the common bile duct, causing obstructive jaundice and cholestatic liver chemistries and predisposing to acute cholangitis and gallstone pancreatitis. Risk is stratified by ASGE criteria and confirmed by MRCP, endoscopic ultrasound, or therapeutic ERCP, which clears the duct before same-admission cholecystectomy.
- Acute pancreatitis
Acute pancreatitis is acinar-cell autodigestion and inflammation of the pancreas, most often from gallstones or alcohol, diagnosed by the revised Atlanta criteria and graded mild, moderately severe, or severe by organ failure. Management centers on early goal-directed lactated Ringer's resuscitation, analgesia, early enteral feeding, and timed ERCP for gallstone pancreatitis with cholangitis, reserving antibiotics for confirmed infected necrosis.
- Primary sclerosing cholangitis
Primary sclerosing cholangitis is an autoimmune fibroinflammatory disease of the large bile ducts, occurring mostly in young men and associated with inflammatory bowel disease, chiefly ulcerative colitis, in 80 to 90% of cases. MRCP showing multifocal strictures and dilations confirms the diagnosis, no drug alters progression, and management centers on endoscopic dilation of dominant strictures, surveillance for cholangiocarcinoma and colorectal cancer, and liver transplantation for advanced disease.
- Pyogenic liver abscess
Pyogenic liver abscess is a polymicrobial hepatic infection that most often seeds from the biliary tract or the portal circulation, presenting with fever, right upper quadrant pain, and a cholestatic liver profile. Diagnosis rests on contrast imaging plus culture, and treatment combines empiric broad-spectrum antibiotics with image-guided drainage for abscesses at or above 3 to 5 cm.
- Sepsis
Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection, identified by an acute rise in SOFA score of 2 points or more in a patient with known or suspected infection. Survival depends on recognizing the pattern early and completing the hour-1 bundle: lactate, blood cultures before antibiotics, broad-spectrum antibiotics such as cefepime 2 g IV every 8 hours, and 30 mL/kg crystalloid for hypotension or a lactate of 4 mmol/L or higher.