ICU · GI & nutrition / surgical

Acute cholangitis and biliary sepsis

Also known as Acute cholangitis · Ascending cholangitis · Biliary sepsis · Biliary obstruction · Charcot triad · Reynolds pentad · Tokyo Guidelines (TG18) · Choledocholithiasis · ERCP biliary drainage · Suppurative cholangitis

Acute cholangitis is bacterial infection of an obstructed biliary tree — a life-threatening emergency. Biliary obstruction raises intraductal pressure, bacteria proliferate in stagnant bile, and infected bile refluxes into the systemic circulation producing bacteraemia and septic shock. Charcot triad (fever + jaundice + RUQ pain) has limited sensitivity and is now only one limb of the Tokyo Guidelines 2018 diagnostic criteria. Reynolds pentad (Charcot + hypotension + altered mental status) indicates severe (Grade III) cholangitis with septic shock. Management: immediate empiric antibiotics — a third-generation cephalosporin first-line for community-acquired disease (E. coli and Klebsiella the main pathogens), broadened for severe or healthcare-associated infection — plus biliary drainage by ERCP timed by severity: urgent drainage for Grade III after initial resuscitation, early drainage for Grade II. Antibiotics alone are insufficient — drainage is the definitive source control.