Ascending Cholangitis
A stone or stricture obstructing the common bile duct lets bacteria ascend and multiply in stagnant, pressurised bile, producing a life-threatening triad of obstruction and infection that demands urgent drainage, not antibiotics alone.
In a nutshell
Obstruction of the common bile duct lets bacteria proliferate in stagnant bile, and the resulting pressure forces infected bile into the bloodstream, causing severe bacteraemia disproportionate to a simple infection. Antibiotics alone cannot fix an obstructed system: urgent drainage is the definitive treatment.
Classic presentation
Right upper quadrant pain, fever with rigors and jaundice (Charcot's triad) in a patient with known or suspected gallstones, sometimes progressing to hypotension and confusion (Reynolds' pentad).
Key points
- Cholangitis requires both obstruction and infection; a stone in the common bile duct is the usual trigger.
- Cholangiovenous reflux (infected, pressurised bile forced into the bloodstream) explains the severity of the bacteraemia.
- Charcot's triad (pain, fever/rigors, jaundice) reflects duct distension, bacteraemia and failed bilirubin excretion respectively.
- Reynolds' pentad (triad plus hypotension and confusion) signals septic shock and an emergency.
- Source control by urgent ERCP (or percutaneous/surgical drainage) is definitive; antibiotics alone will not clear an obstructed system.
First-line investigation
Blood cultures, lactate and LFTs alongside urgent ultrasound, without delaying resuscitation and antibiotics.
First-line management
Treat as sepsis immediately with fluids, oxygen and IV antibiotics, then arrange urgent ERCP for biliary decompression.
Exam traps
- Do not wait for imaging before starting sepsis management; resuscitation and antibiotics come first in a septic patient.
- Antibiotics alone are not curative; the obstruction must be drained, usually by ERCP.
- Confusing cholangitis with cholecystitis is a common error: jaundice and rigors point to duct-level obstruction and infection, not gallbladder-only disease.
Educational content pending clinical review. Not medical advice.