Acute (Ascending) Cholangitis ✅

Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

🚨 Acute (ascending) cholangitis = biliary obstruction + infection leading to rapid sepsis. 💡 Classic: Charcot’s triad → fever 🌡️ + jaundice 🟡 + RUQ pain 🤕. ⚠️ Reynolds’ pentad (↑ severity): + hypotension 💉 + confusion 🧠 → septic shock. 👉 Medical emergency → requires urgent IV antibiotics + early biliary decompression (usually ERCP). 🧠 Key principle: source control (drainage) is lifesaving, antibiotics alone are insufficient.

📌 About

• 🔥 Infection occurs due to increased biliary pressure allowing bacterial translocation into bloodstream → bacteraemia.
• 🪨 Most commonly due to common bile duct (CBD) stones.
• 📈 Risk increases with age, prior biliary disease, or instrumentation (e.g. ERCP, stents).
• ⚠️ Rapid progression to sepsis and multi-organ failure if untreated.

🦠 Aetiology & Microbiology

• Obstruction causes:
  • 🪨 Gallstones (most common)
  • 🧬 Malignancy (cholangiocarcinoma, pancreatic cancer)
  • 🧵 Benign strictures (post-surgical, PSC)
  • 🪱 Parasites (rare in UK; e.g. liver flukes)
• Typical organisms (enteric flora):
  • Gram −ve: E. coli, Klebsiella, Enterobacter
  • Gram +ve: Enterococcus, Streptococcus
  • ⚠️ Polymicrobial infection common

📊 Clinical Features

• 🌡️ Fever ± rigors
• 🤕 RUQ abdominal pain
• 🟡 Jaundice
• ⚡ Sepsis features: tachycardia, hypotension, confusion
• 🧻 Obstructive pattern: dark urine, pale stools, pruritus

Exam insight: Charcot’s triad is only present in ~20–50% → absence does NOT exclude cholangitis.

🔎 Diagnosis (Tokyo Guidelines 2018)

• A. Systemic inflammation: fever/rigors OR ↑ CRP/WCC
• B. Cholestasis: jaundice OR abnormal LFTs (↑ ALP, GGT, bilirubin)
• C. Imaging: biliary dilatation or evidence of obstruction

• ✅ Suspected: A + (B or C)
• ✅ Definite: A + B + C

⚠️ Severity grading (Tokyo):

• 🟥 Severe (Grade III): organ dysfunction → urgent drainage
• 🟧 Moderate: early drainage
• 🟩 Mild: antibiotics ± delayed drainage

🧪 Investigations (NICE-aligned approach)

• 🩸 Bloods: FBC, U&E, LFTs, CRP, clotting (important pre-ERCP)
• 🧫 Blood cultures: before antibiotics
• 🖥️ Imaging:
  • 🥇 Ultrasound (USS) first-line → duct dilatation, stones
  • 🧲 MRCP if diagnosis unclear
  • 📡 CT if complications or alternative diagnosis
  • 🔧 ERCP = diagnostic + therapeutic (NOT first-line diagnostic unless intervention needed)

⚠️ Complications

• 🦠 Sepsis → septic shock
• 🫀 Multi-organ failure (AKI, hepatic dysfunction)
• 🧠 Encephalopathy
• 🧫 Liver abscess
• ⏳ Recurrent episodes → secondary biliary cirrhosis

💊 Management (NICE + UK practice)

1. 🆘 Immediate resuscitation (Sepsis 6)
   • 💉 IV fluids, oxygen, lactate measurement
   • 🧫 Blood cultures BEFORE antibiotics
   • 📊 Close monitoring (NEWS2)
2. 💊 Empirical IV antibiotics (as per local policy)
   • First-line (UK common): piperacillin–tazobactam
   • Alternative: co-amoxiclav ± metronidazole
   • Severe sepsis / resistant risk: meropenem
   • 👉 Tailor to culture results
3. 🔧 Definitive management = biliary decompression
   • 🥇 ERCP → sphincterotomy, stone extraction, stent
   • 🩺 Percutaneous transhepatic drainage if ERCP not possible
   • ⚠️ Timing:
     • Severe: urgent (<24h)
     • Moderate: early (<48–72h)
4. 🔪 Definitive prevention
   • Elective laparoscopic cholecystectomy once stabilised (if gallstones)
5. 🤝 Supportive care
   • ICU if organ dysfunction
   • Early senior + MDT involvement (surgery, gastro, IR)

💡 Clinical Pearls

• 🚨 Suspected cholangitis = treat as sepsis + call for ERCP early.
• 🧠 Antibiotics alone are not definitive → obstruction must be relieved.
• ⚠️ Elderly may present atypically (delirium, sepsis without pain).
• 📉 Delay in drainage = ↑ mortality.
• 📝 OSCE: say “Sepsis 6 + urgent ERCP” for full marks.

📚 References

• NICE CG188 – Gallstone disease
• NICE NG51 – Sepsis: recognition and management
• NICE NG12 – Suspected cancer
• Tokyo Guidelines 2018 (TG18) – Acute cholangitis diagnostic and severity criteria
• BSG (British Society of Gastroenterology) guidance on ERCP and biliary disease

Teaching Commentary 🧑‍⚕️

Ascending cholangitis is fundamentally a problem of pressure + infection: biliary obstruction increases ductal pressure, allowing bacteria to reflux into the bloodstream → bacteraemia and sepsis. This explains why antibiotics alone are insufficient—you must relieve the obstruction to achieve source control. The Tokyo Guidelines formalise diagnosis and severity grading, which directly guides timing of ERCP. From a UK perspective, NICE emphasises early recognition of sepsis (NEWS2, Sepsis 6) alongside specialist escalation. Clinically, always think of cholangitis in an unwell jaundiced patient—especially with deranged cholestatic LFTs—because delay in drainage is the main modifiable driver of mortality.