Ascending Cholangitis
Summary
Ascending cholangitis is a life-threatening bacterial infection of the biliary tree, usually caused by obstruction (most commonly choledocholithiasis). The combination of bile stasis and bacterial overgrowth leads to bacteremia and sepsis. The classic presentation is Charcot's triad (fever/rigors, right upper quadrant pain, and jaundice); when hypotension and confusion are added, it becomes Reynolds' pentad, indicating severe sepsis. Emergency management includes resuscitation, broad-spectrum antibiotics, and urgent biliary drainage, typically via ERCP. Without prompt treatment, mortality exceeds 50%.
Key Facts
- Cause: Biliary obstruction (stones 60-70%, strictures, malignancy)
- Organisms: E. coli (25-50%), Klebsiella, Enterococcus, Bacteroides
- Charcot's triad: Fever + RUQ pain + Jaundice (50-70% of patients)
- Reynolds' pentad: Charcot's + Confusion + Hypotension (shock)
- Mortality: 10-30% (higher without prompt drainage)
- Key treatment: Antibiotics + Urgent ERCP (within 24-48 hours)
Clinical Pearls
Charcot's Triad is Not Sensitive: Only 50-70% of patients present with the full triad. Fever is the most consistent feature. Have a low threshold for suspecting cholangitis in any patient with biliary obstruction and systemic illness.
Reynolds' Pentad = Emergency: The addition of confusion and hypotension indicates severe sepsis/septic shock with high mortality. These patients need resuscitation and urgent source control (ERCP or PTC).
The 24-48 Hour Window: Early biliary drainage (within 24-48 hours) is associated with reduced mortality. Do not delay ERCP waiting for antibiotics to "settle" the infection.
Why This Matters Clinically
Ascending cholangitis is a medical and surgical emergency. Delay in diagnosis or treatment leads to sepsis, multi-organ failure, and death. Recognition of the clinical syndrome and rapid initiation of antibiotics plus biliary drainage saves lives.
Incidence & Prevalence
- Incidence: 1-3% of patients with gallstones develop cholangitis
- Accounts for: 6-9% of patients admitted with acute biliary disease
- Trend: Stable; may increase with ageing population
Demographics
| Factor | Details |
|---|---|
| Age | Peak 50-70 years |
| Sex | Slightly more common in women (gallstone prevalence) |
| Ethnicity | Asian populations (hepatolithiasis) |
| Geography | Southeast Asia (recurrent pyogenic cholangitis) |
Risk Factors
| Factor | Impact |
|---|---|
| Choledocholithiasis | Most common cause (60-70%) |
| Biliary strictures (benign/malignant) | Increasing cause |
| Previous biliary surgery or ERCP | Biliary stent complications |
| Immunosuppression | Worse outcomes |
| Biliary-enteric anastomosis | Loss of sphincter barrier |
Mechanism
Step 1: Biliary Obstruction
- Most commonly CBD stones
- Strictures (post-surgical, PSC, malignant)
- Biliary stent occlusion
- Parasites (Ascaris, liver flukes — Asia)
Step 2: Bacterial Colonisation
- Normal bile is sterile (sphincter of Oddi barrier)
- Obstruction allows bacterial overgrowth
- Common organisms: E. coli, Klebsiella, Enterococcus, Bacteroides
Step 3: Increased Biliary Pressure
- Obstruction causes bile retention
- Biliary pressure rises (normally 10-15 cmH2O)
- At greater than 25 cmH2O, cholangio-venous reflux occurs
Step 4: Bacteremia and Sepsis
- Bacteria enter systemic circulation
- Sepsis, SIRS, septic shock
- Multi-organ dysfunction syndrome
Classification
Tokyo Guidelines (TG18) Severity:
| Grade | Criteria | Management |
|---|---|---|
| Grade I (Mild) | No organ dysfunction, responds to initial treatment | Antibiotics + elective drainage |
| Grade II (Moderate) | 2+ of: WCC greater than 12 or less than 4, fever greater than 39°C, age ≥75, bili greater than 85 μmol/L | Antibiotics + early drainage (24-48h) |
| Grade III (Severe) | Cardiovascular, neurological, respiratory, renal, hepatic, or haematological dysfunction | Resuscitation + urgent drainage (12-24h) |
Symptoms
Charcot's Triad (Classic):
Additional Symptoms:
Signs
Red Flags
[!CAUTION] Reynolds' Pentad — Indicates severe/life-threatening cholangitis:
- Charcot's triad PLUS
- Confusion (altered mental status)
- Hypotension (systolic less than 90 mmHg or requiring vasopressors)
Other Red Flags:
- Multi-organ failure (oliguria, hypoxia)
- Coagulopathy (DIC)
- Failed response to antibiotics
Structured Approach
General:
- Vital signs (fever, tachycardia, hypotension)
- Signs of sepsis (warm peripheries, confusion, hypotension)
- Jaundice (scleral icterus)
Abdominal:
- RUQ tenderness (usually positive)
- Murphy's sign (may be positive if concurrent cholecystitis)
- Hepatomegaly (may be present)
- Peritonism (if perforation or severe inflammation)
Special Tests
| Test | Technique | Positive Finding | Purpose |
|---|---|---|---|
| RUQ palpation | Palpate right upper quadrant | Tenderness | Biliary pathology |
| Murphy's sign | Palpate during inspiration | Inspiratory arrest | Cholecystitis (may coexist) |
| Consciousness | AVPU or GCS | Confusion | Severity (Reynolds') |
First-Line
- Observations — Fever pattern, NEWS score
- Blood cultures — Before antibiotics (positive in 20-70%)
- Routine bloods — FBC, U&E, LFTs, CRP, lactate
Laboratory Tests
| Test | Expected Finding | Purpose |
|---|---|---|
| FBC | Leukocytosis (may be leukopenia in severe sepsis) | Inflammatory response |
| LFTs | Raised ALP, GGT (cholestatic); raised bilirubin | Biliary obstruction |
| CRP | Elevated | Inflammatory marker |
| Lactate | Elevated in severe sepsis | Severity marker |
| Coagulation | Prolonged PT/INR (vitamin K malabsorption, DIC) | Severity, pre-procedure |
| Blood cultures | Positive in 20-70% | Identify organism |
Imaging
| Modality | Findings | Indication |
|---|---|---|
| Ultrasound | Dilated CBD (greater than 6mm), stones, sludge | First-line |
| MRCP | CBD stones, strictures, anatomy | If unclear, pre-ERCP |
| CT abdomen | Biliary dilatation, cause of obstruction, exclude other pathology | Complex cases |
| ERCP | Diagnostic and therapeutic | Definitive investigation and treatment |
Diagnostic Criteria
Tokyo Guidelines (TG18):
- A: Systemic inflammation (fever greater than 38°C and/or WCC greater than 10)
- B: Cholestasis (jaundice and/or abnormal LFTs)
- C: Imaging (biliary dilatation and/or evidence of aetiology)
Definite diagnosis: A + B + C Suspected diagnosis: A + B or A + C
Management Algorithm
SUSPECTED ASCENDING CHOLANGITIS
↓
┌─────────────────────────────────────────┐
│ RESUSCITATION (Sepsis 6) │
│ O2, IV access, blood cultures, lactate │
│ IV antibiotics, IV fluids │
└─────────────────────────────────────────┘
↓
┌─────────────────────────────────────────┐
│ CONFIRM DIAGNOSIS │
│ LFTs, USS, MRCP if needed │
└─────────────────────────────────────────┘
↓
┌─────────────────────────────────────────┐
│ SEVERITY GRADING (TG18) │
├─────────────────────────────────────────┤
│ GRADE I: Antibiotics + elective ERCP │
│ GRADE II: Antibiotics + ERCP 24-48h │
│ GRADE III: Resuscitate + ERCP 12-24h │
│ (or PTC if ERCP not possible)│
└─────────────────────────────────────────┘
↓
┌─────────────────────────────────────────┐
│ BILIARY DRAINAGE │
│ ERCP: Sphincterotomy + stent/stone │
│ extraction │
│ PTC: If ERCP fails or inaccessible │
│ Surgery: Rarely, if above unavailable │
└─────────────────────────────────────────┘
↓
┌─────────────────────────────────────────┐
│ DEFINITIVE MANAGEMENT │
│ Cholecystectomy (if gallstones) │
│ Treat underlying cause │
└─────────────────────────────────────────┘
Emergency Management
Sepsis Six (Within 1 Hour):
- High-flow oxygen
- Blood cultures
- IV antibiotics
- IV fluid resuscitation
- Lactate measurement
- Urine output monitoring
Antibiotic Choice:
- First-line: Piperacillin-tazobactam 4.5g TDS IV
- Alternative: Ciprofloxacin + metronidazole
- Severe/shock: Add gentamicin
- Duration: 5-7 days (shorter if source controlled)
Biliary Drainage
| Method | Indication | Notes |
|---|---|---|
| ERCP | First-line | Sphincterotomy, stone extraction, stent |
| PTC | ERCP failed or inaccessible | Percutaneous transhepatic cholangiography |
| EUS-guided drainage | Emerging option | Specialist centres |
| Surgical drainage | Last resort | If above unavailable |
Timing of Drainage
- Grade III (severe): Within 12-24 hours
- Grade II (moderate): Within 24-48 hours
- Grade I (mild): Elective (within hospital admission)
Disposition
- Admit: All patients with cholangitis
- ICU/HDU: Grade III, vasopressor requirement, multi-organ failure
- Follow-up: Cholecystectomy if gallstone aetiology; address underlying cause
Immediate
| Complication | Incidence | Presentation | Management |
|---|---|---|---|
| Septic shock | 10-30% | Hypotension, multi-organ failure | Resuscitation, vasopressors, urgent drainage |
| Multi-organ failure | 5-15% | Renal, respiratory, hepatic failure | ICU, organ support |
| Liver abscess | 5-10% | Persistent fever, RUQ pain | Drainage (percutaneous or surgical) |
Early (Days)
- ERCP complications: Pancreatitis (5%), bleeding, perforation
- Recurrent obstruction: Stent blockage
- Persistent bacteraemia: May indicate undrained collection
Late (Weeks-Months)
- Recurrent cholangitis: If underlying cause not addressed
- Biliary strictures: Post-inflammatory
- Secondary biliary cirrhosis: Chronic obstruction
Outcomes
| Variable | Outcome |
|---|---|
| Mortality (mild cholangitis) | Less than 5% |
| Mortality (severe/shock) | 10-30% |
| Mortality (without drainage) | Greater than 50% |
| ERCP success rate | 90-95% |
Prognostic Factors
Good Prognosis:
- Mild disease (TG18 Grade I)
- Early antibiotics and drainage
- Young, no comorbidities
- Stone aetiology (removable)
Poor Prognosis:
- Severe disease (TG18 Grade III)
- Delayed drainage
- Malignant obstruction
- Advanced age, comorbidities
- Healthcare-associated infection (resistant organisms)
Key Guidelines
- Tokyo Guidelines 2018 (TG18) — Diagnosis and management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2018
- EASL Clinical Practice Guidelines on Biliary Stones (2016).
- NICE CKS Gallstones — Clinical Knowledge Summary.
Key Studies
Tokyo Guidelines (TG18) — Evidence-based severity grading
- Key finding: Severity stratification guides timing of drainage
- Clinical Impact: Standard classification used worldwide
Leung et al. (1992) — ERCP vs surgery for cholangitis
- Randomised trial
- Key finding: ERCP associated with lower morbidity and mortality than surgery
- Clinical Impact: ERCP became first-line for biliary drainage
Evidence Strength
| Intervention | Level | Key Evidence |
|---|---|---|
| Antibiotics for cholangitis | 2a | Guideline consensus |
| Early ERCP (severe) | 1b | TG18, cohort studies |
| PTC if ERCP fails | 2b | Case series, expert consensus |
What is Ascending Cholangitis?
Ascending cholangitis is a serious infection of the bile ducts — the tubes that carry bile from your liver to your gut. It usually happens when something blocks these tubes, most commonly a gallstone. When bile cannot flow, bacteria multiply and can enter your bloodstream, causing a severe infection (sepsis).
Why does it matter?
Without treatment, ascending cholangitis can be life-threatening. The infection can spread quickly, causing your blood pressure to drop and your organs to start failing. However, with prompt antibiotics and a procedure to unblock the bile duct, most people recover well.
How is it treated?
- Antibiotics: Strong antibiotics through a drip to fight the infection.
- Fluids and support: Fluids through a drip to keep your blood pressure up.
- ERCP procedure: A camera passed down your throat into your gut to unblock or widen the bile duct and remove any stones.
- Surgery: Occasionally needed if the camera procedure is not possible.
What to expect
- You will need to stay in hospital
- You may be in intensive care if the infection is severe
- Most people improve quickly once the bile duct is unblocked
- You may need your gallbladder removed later to prevent recurrence
When to seek help
Go to A&E or call 999 if you have:
- High fever with shivering
- Severe pain in the upper right side of your tummy
- Yellow skin or eyes (jaundice)
- Confusion or drowsiness
- Feeling very unwell
Primary Guidelines
- Miura F, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis. J Hepatobiliary Pancreat Sci. 2018;25(1):17-30. PMID: 29032610
Key Studies
- Kiriyama S, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):31-40. PMID: 29095573
- Leung JW, et al. Endoscopic drainage for acute suppurative cholangitis. N Engl J Med. 1987;317(26):1638-41. PMID: 3317053
Further Resources
- British Liver Trust: britishlivertrust.org.uk
- NHS Gallstones: nhs.uk/conditions/gallstones
Last Reviewed: 2025-12-24 | MedVellum Editorial Team
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.