Cholangitis vs cholecystitis — TG18 and source control

Spectrum framing. Biliary colic is transient cystic-duct obstruction with self-limiting pain and no systemic inflammation. Acute cholecystitis is sustained cystic-duct obstruction with wall inflammation (Murphy sign, wall thickening, pericholecystic fluid). Ascending cholangitis is infection of an obstructed bile duct with systemic inflammation, cholestasis and duct imaging findings — a sepsis + source-control emergency.^[1][2]

TG18 severity. Both cholecystitis and cholangitis use Grade I (mild), II (moderate local/systemic features without organ failure), and III (organ dysfunction: CVS needing pressors, CNS, respiratory, renal, hepatic INR, platelets). Grade III cholangitis needs urgent drainage plus organ support.^[1]

Therapy. Antibiotics (e.g. ceftriaxone 2 g IV + metronidazole 500 mg IV, or pip-tazo 4.5 g IV) start early for infected biliary disease, but antibiotics do not replace drainage of pus under pressure in the duct.^[3] Cholangitis → ERCP (or PTBD). Cholecystitis → early laparoscopic cholecystectomy when fit; percutaneous cholecystostomy for the unfit/acalculous critically ill.

Exam trap. Charcot triad is incomplete in many confirmed cases (sensitivity 46 per cent in a prospective ERCP cohort) — diagnose on TG18 domains, not triad completeness. Always exclude ACS in epigastric pain with an ECG.^[1][4]