Acute cholangitis (ascending cholangitis) refers to a bacterial infection of the biliary tract, typically secondary to biliary obstruction and stasis (e.g., due to choledocholithiasis, biliary stricture). Charcot triad, which consists of RUQ pain, fever, and jaundice, is the classical clinical manifestation of acute cholangitis though not all patients manifest with the triad. The diagnosis of acute cholangitis is based on a combination of characteristic clinical features, evidence of systemic inflammation (i.e., leukocytosis, ↑ CRP), and evidence of cholestasis (e.g., elevated direct bilirubin, GGT, and ALP). Imaging is primarily used to identify the underlying cause of biliary obstruction. Empiric antibiotic therapy and urgent biliary drainage (e.g., ERCP + papillotomy, EUS-guided biliary drainage) within 48 hours of presentation are the mainstays of treatment. Treatment of the underlying cause (e.g., ERCP-guided stone extraction or CBD stenting) may be performed at the same time as urgent biliary drainage in stable patients with mild cholangitis or deferred until clinical improvement in patients with severe cholangitis.
Biliary tract obstruction → bile stasis with increased intraductal pressure → bacterial translocation into the bile ducts ; → bacterial infection ascends the biliary tract (even into the hepatic ducts) ; 
- Choledocholithiasis (most common) 
- Biliary strictures
- Malignant obstruction (e.g., due to cholangiocarcinoma, pancreatic cancer, etc)
- Extrinsic compression (e.g., Mirizzi syndrome)
- Parasitic infection (e.g., liver fluke, hydatid cyst, Ascaris spp.)
- Acute pancreatitis
- Periampullary duodenal diverticulum 
- Contamination of bile with intestinal contents
- Charcot cholangitis triad (25–70% of patients present with all three features) ; 
- Reynolds pentad; : Charcot cholangitis triad PLUS hypotension and mental status changes
- Features of sepsis, septic shock, and multiorgan dysfunction may be present, depending on the severity of disease at presentation.
- Elderly patients may present with nonspecific symptoms such as confusion; pain and jaundice may be absent. 
Acute cholangitis may present atypically, particularly in older patients. A high index of suspicion is required to avoid delays in diagnosis and treatment. 
Acute cholangitis is diagnosed based on systemic signs of inflammation (fever, leukocytosis, ↑ CRP) in combination with signs of cholestasis (jaundice, ↑ GGT, ↑ ALP) and/or characteristic imaging findings (e.g., dilated CBD, periductal inflammation). Once the diagnosis is confirmed, disease severity should be assessed to determine the best approach to management (see “Severity grading of acute cholangitis”).
Diagnostic criteria 
Charcot triad is not included in the diagnostic criteria because, although specific, it is not a sensitive criterion and may even be absent in patients with acute cholangitis. 
Diagnostic criteria for acute cholangitis 
|Systemic signs of inflammation|
|Signs of cholestasis|
Laboratory studies 
- Tests to support the clinical diagnosis
- Tests to assess severity of disease (see “ ”)
- Tests to evaluate differential diagnoses
Atypical presentations are common in elderly patients. Consider obtaining liver chemistries to evaluate for acute cholangitis in acutely ill elderly patients with nonspecific symptoms. 
Acute cholangitis cannot be diagnosed with imaging alone. The goal of imaging is to evaluate for biliary obstruction that may have precipitated cholangitis. 
- Indication: preferred first-line imaging modality in patients presenting with suspected cholangitis 
- Dilated common bile duct: See ''Diagnosis of choledocholithiasis” for details.
- Dilated intrahepatic bile ducts: indicates obstructive cholestasis
- Thickened bile duct walls 
- Evidence of underlying etiology, such as:
RUQ ultrasound is not sufficiently sensitive to definitively rule out biliary obstruction. Obtain cross-sectional imaging (i.e., CT abdomen or MRCP) in patients with a high pretest probability of acute cholangitis and a negative RUQ ultrasound. 
CT scan with IV contrast 
- Indications 
Supportive findings 
- Concentric thickening and heterogeneous enhancement of the walls of the biliary tree 
- Bile duct dilation
- Periductal edema
- Evidence of underlying cause: choledocholithiasis, biliary tumor , biliary-enteric fistula, hydatid cyst, etc.
- Evidence of complications: pericholecystic or liver abscess, portal vein thrombosis.
Scrollable CT image series
- Indication: an alternative confirmatory imaging modality if ultrasound is inconclusive 
- Supportive findings: similar to CT findings
RUQ pain with fever with/without jaundice
- Acute calculus cholecystitis or its complications
- Acalculous cholecystitis
- Liver abscess
- Acute hepatitis
- Bile leak (iatrogenic, e.g., post-ERCP, postcholecystectomy)
- Acute necrotizing pancreatitis
- See ''RUQ'' in “Differential diagnoses of acute abdominal pain.”
- See “Differential diagnoses of abdominal pain.”
- Dilated biliary duct: See ''Differential diagnoses'' in “Choledocholithiasis.”
- See also “Overview of biliary disease”.
The differential diagnoses listed here are not exhaustive.
Once the diagnosis is confirmed, disease severity should be assessed to determine the best approach to treatment. 
|Severity grading for acute cholangitis |
|Grades of severity||Grading criteria|
(Mild acute cholangitis)
(Moderate acute cholangitis)
(Severe acute cholangitis)
Empiric antibiotic therapy and urgent biliary drainage are the mainstays of treatment of acute cholangitis. The choice and timing of both biliary drainage and any procedure to treat the underlying cause are dictated by the severity of the disease at presentation (see “Severity grading of acute cholangitis”).
Initial management 
- Stabilize the patient as needed.
Administer to all patients.
- Grade III acute cholangitis: within one hour of presentation 
- Grade I–II acute cholangitis: within 4–6 hours of presentation 
- Determine the need and timing for urgent biliary drainage and treatment of the underlying cause, based on (see “Definitive management”).
- Identify and treat concurrent choledocholithiasis (see “Diagnosis of choledocholithiasis”).
- Provide : e.g., analgesics (preferably NSAIDs), antiemetics, nasogastric tube insertion as needed, electrolyte repletion
- Keep patients NPO.
- Consult gastroenterology, interventional radiology, and/or surgery for urgent biliary drainage and decompression.
Initiate supportive therapy and broad-spectrum antibiotics as early as possible!
Definitive management 
Grade I acute cholangitis
- Antibiotic therapy alone may be sufficient.
- Consider urgent biliary drainage within 24–48 hours of presentation in patients with either of the following:
- Underlying cause
- If antibiotics are given alone: Treat electively, after acute symptoms resolve.
- If biliary drainage is performed: Treat concurrently (i.e., a single-stage procedure).
Grade II acute cholangitis
- Urgent biliary drainage within 24–48 hours of presentation
- Underlying cause
- Treat concurrently with biliary drainage (i.e., a single-stage procedure)
- OR treat electively, after the patient improves with biliary drainage (i.e., a two-stage procedure)
Grade III acute cholangitis
- Urgent biliary drainage within 24 hours of presentation 
- Treat the underlying cause once the patient's condition improves after urgent biliary drainage (i.e., a two-stage procedure)
Urgent drainage of infected bile is imperative in order to achieve rapid source control in patients with grade II–III acute cholangitis.
Procedures for biliary drainage 
Therapeutic ERCP-guided transpapillary biliary drainage
- Indication: preferred biliary drainage procedure in acute cholangitis 
- ERCP with papillotomy (sphincterotomy): Consider in patients with grade I–II acute cholangitis with no evidence of coagulopathy. ]
- ERCP with temporary biliary stenting: Consider in patients with grade III acute cholangitis, uncorrected coagulopathy, biliary stricture, or cholangiocarcinoma. 
EUS-guided biliary drainage 
- Procedure: Under EUS guidance, a fistula is created and a stent placed between the stomach/duodenum and the CBD/(dilated) hepatic duct to allow for internal biliary drainage.
Double balloon enteroscopy-assisted ERCP 
- Indication: preferred procedure for biliary drainage in patients with altered upper gastrointestinal anatomy, if endoscopy expertise is available
- Procedure: An enteroscope is used to maneuver through the gastroenteric/enteroenteric anastomosis until the duodenal papilla is identified; after which ERCP-guided papillotomy or stenting may be performed.
- Percutaneous transhepatic biliary drainage (PTBD) 
- Surgical choledochotomy with T-tube biliary drainage 
- Indication: Consider if minimally invasive endoscopic and percutaneous biliary drainage procedures are unsuccessful or not feasible
- Procedure: The CBD is opened laparoscopically or via open surgery (choledochotomy), a T-tube placed within the CBD, and the choledochotomy closed around the T-tube. The long limb of the T-tube is brought out through the abdominal wall to allow for external biliary drainage. 
- Double balloon enteroscopy-assisted ERCP 
Procedures for treatment of the underlying cause 
- For choledocholithiasis 
- For biliary stricture: ERCP and CBD stenting
- For parasitic infections (rare): ERCP-guided parasite extraction and anthelmintics 
- See also “Mirizzi syndrome”, “Biliary-enteric fistula”, and “Cholangiocarcinoma.”
All patients require inpatient management.
- IV access with two large-bore peripheral IVs
- Blood cultures (2 sets)
- Provide initial hemodynamic support and respiratory support as needed.
- Initial supportive care (see '' '')
- Determine severity (see '' '').
- IV antibiotics (see '' '')
- Urgent gastroenterology, interventional radiology, and/or surgery consult for biliary drainage and decompression
- Serial abdominal examination
- ICU transfer if sepsis or shock are present