Overview
Ascending Cholangitis
Topic Overview
Summary
Ascending cholangitis is bacterial infection of the biliary tree, usually due to biliary obstruction (commonly CBD stones). Classic presentation is Charcot's triad: fever, right upper quadrant pain, and jaundice. Severe cases present with Reynolds' pentad (adding confusion and hypotension). Treatment is IV antibiotics, resuscitation, and urgent biliary drainage (ERCP or PTC). This is a life-threatening condition if drainage is delayed.
Key Facts
- Cause: Biliary obstruction + bacterial infection (E. coli, Klebsiella, Enterococcus)
- Charcot's triad: Fever + RUQ pain + jaundice (50-70% of cases)
- Reynolds' pentad: Charcot's triad + confusion + hypotension (severe/suppurative)
- Treatment: IV antibiotics + urgent biliary drainage (ERCP preferred)
- Prognosis: Good with early drainage; high mortality if delayed
Clinical Pearls
Charcot's triad is present in only 50-70% — have a low threshold in any septic patient with abnormal LFTs
ERCP within 24-48 hours is life-saving — do not delay
Reynolds' pentad indicates severe cholangitis — needs ICU and urgent drainage
Why This Matters Clinically
Ascending cholangitis kills quickly without drainage. Recognising the classic presentation and escalating for urgent ERCP is critical. Antibiotics alone are insufficient.
Visual Summary
Visual assets to be added:
- ERCP showing CBD stone extraction
- Biliary anatomy diagram
- Tokyo Guidelines severity chart
- Ascending cholangitis algorithm
Epidemiology
Incidence
- Most common cause: CBD stone (80%)
- Other causes: Stricture, stent occlusion, malignancy
- Affects all ages; more common in elderly
Demographics
- Female predominance (gallstones more common)
- Elderly at higher risk
Causes of Biliary Obstruction
| Cause | Frequency |
|---|---|
| CBD stone | 80% |
| Biliary stricture | 5-10% |
| Pancreatic/cholangiocarcinoma | 5-10% |
| Stent occlusion | Variable |
| Parasitic (Ascaris, liver fluke) | Endemic areas |
Pathophysiology
Mechanism
- Biliary obstruction (stone, stricture, tumour)
- Bile stasis → bacterial colonisation (gut flora ascend)
- Increased biliary pressure → bacteria enter bloodstream
- Sepsis, bacteraemia, multi-organ dysfunction
Common Organisms
| Organism | Percentage |
|---|---|
| E. coli | 25-50% |
| Klebsiella | 15-20% |
| Enterococcus | 10-20% |
| Pseudomonas | 5-10% |
| Anaerobes (Bacteroides) | 5-10% |
Severity Progression
- Mild: Infection responds to antibiotics; drainage elective
- Moderate: Needs urgent drainage
- Severe (suppurative): Pus under pressure; septic shock; needs emergent drainage
Clinical Presentation
Charcot's Triad (Classic)
| Feature | Frequency |
|---|---|
| Fever/rigors | 90% |
| RUQ pain | 70% |
| Jaundice | 60% |
| Full triad | 50-70% |
Reynolds' Pentad (Severe)
Other Features
Red Flags
| Finding | Significance |
|---|---|
| Septic shock | Urgent drainage needed |
| Confusion | Severe cholangitis (Reynolds') |
| Bilirubin over 50 | Significant obstruction |
| Rapid deterioration | Consider ICU |
Charcot's triad PLUS
Confusion (septic encephalopathy)
Hypotension (septic shock)
Clinical Examination
Vital Signs
- Fever (often spiking, with rigors)
- Tachycardia
- Hypotension (severe)
Abdominal Examination
- RUQ tenderness
- Jaundice
- Murphy's sign often negative (distinguishes from cholecystitis)
Systemic Signs
- Confusion
- Signs of dehydration
- Sepsis (warm peripheries, bounding pulse initially; then cold, shut down)
Investigations
Blood Tests
| Test | Findings |
|---|---|
| WCC | Elevated (often significantly) |
| CRP | Elevated |
| LFTs | Raised bilirubin, ALP, GGT; ALT may be elevated |
| Blood cultures | Positive in 30-50% |
| Lactate | Elevated in sepsis |
| U&E, creatinine | Renal function (may be impaired) |
Imaging
| Modality | Role |
|---|---|
| Ultrasound | First-line; shows dilated bile ducts, stones (may miss CBD stones) |
| MRCP | More sensitive for CBD stones if USS inconclusive |
| CT abdomen | Alternative; shows obstruction, complications |
| ERCP | Diagnostic and therapeutic (not purely diagnostic now) |
Tokyo Guidelines Severity Grading
| Grade | Definition | Management |
|---|---|---|
| Grade I (Mild) | No organ dysfunction; responds to antibiotics | ERCP within 24-48h |
| Grade II (Moderate) | Any 2 of: WCC over 12, fever over 39°C, age over 75, bilirubin over 85 | Urgent ERCP |
| Grade III (Severe) | Organ dysfunction (cardiovascular, renal, neurological) | Emergent drainage + ICU |
Classification & Staging
Tokyo Guidelines 2018
| Grade | Criteria | Drainage Timing |
|---|---|---|
| Mild (I) | No organ dysfunction, responds to antibiotics | 24-48h |
| Moderate (II) | Early signs of severity | Urgent (under 24h) |
| Severe (III) | Organ dysfunction | Emergent (within hours) |
Management
Resuscitation
- IV access, IV fluids
- Sepsis 6 bundle if septic
- Monitor urine output
Antibiotics (Immediately After Cultures)
| Regimen | Notes |
|---|---|
| Piperacillin-tazobactam | First-line if severe |
| Co-amoxiclav | Alternative if mild |
| Ciprofloxacin + metronidazole | If penicillin allergy |
Biliary Drainage — The Definitive Treatment
| Modality | Indication |
|---|---|
| ERCP + sphincterotomy ± stone extraction | First-line; therapeutic and diagnostic |
| Percutaneous transhepatic cholangiography (PTC) | If ERCP fails or not accessible |
| Surgical drainage | Rarely needed; if ERCP/PTC not possible |
Timing of Drainage
| Severity | Timing |
|---|---|
| Mild | Within 24-48 hours |
| Moderate | Within 24 hours |
| Severe | Within hours (emergent); after initial stabilisation |
Post-ERCP
- Continue antibiotics (usually 5-7 days)
- Plan definitive treatment for CBD stones (cholecystectomy + ERCP or laparoscopic CBD exploration)
Complications
Of Cholangitis
- Septic shock
- Multi-organ failure
- Hepatic abscess
- Death (if delayed drainage)
Of ERCP
- Post-ERCP pancreatitis (3-5%)
- Bleeding
- Perforation
- Cholangitis (if incomplete drainage)
Prognosis & Outcomes
Mortality
- Overall: 5-10% with treatment
- Severe/suppurative: 10-30%
- Mortality approaches 100% without drainage
Factors Associated with Poor Outcome
- Delayed drainage
- Organ dysfunction at presentation
- Malignant cause
- Elderly, comorbid patients
Evidence & Guidelines
Key Guidelines
- Tokyo Guidelines 2018 (TG18): Acute Cholangitis
- NICE NG104: Gallstone Disease
Key Evidence
- Early ERCP reduces mortality
- Tokyo Guidelines validated for severity stratification
Patient & Family Information
What is Ascending Cholangitis?
Ascending cholangitis is an infection of the bile ducts, usually caused by a blockage such as a gallstone. It is a serious condition that needs urgent treatment.
Symptoms
- Fever and chills
- Yellowing of the skin and eyes (jaundice)
- Tummy pain (right side)
Treatment
- Antibiotics through a drip
- A procedure (ERCP) to remove the blockage and drain the bile
What Happens Next?
- Most people recover well with treatment
- You may need surgery to remove your gallbladder
Resources
References
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
- Lai EC, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med. 1992;326(24):1582-1586. PMID: 1584258