Upper GI & Hepatobiliary Surgery

Ascending Cholangitis

Bacteria multiply in bile trapped behind an obstructed common bile duct, and rising pressure in the duct drives them into the bloodstream.

In a nutshell

Acute cholangitis is infection in bile trapped behind an obstructed common bile duct. Resuscitate on the sepsis pathway, give broad-spectrum intravenous antibiotics within 1 hour of calculating NEWS2, then get the duct drained, because antibiotics cannot relieve an obstruction.

Classic presentation

An older patient with known gallstones develops rigors, right upper quadrant pain and jaundice, with cholestatic liver tests and a dilated common bile duct on ultrasound.

Key points

Bile is normally sterile and flowing. Cholangitis needs obstruction plus infection, which is why relieving the obstruction is the treatment and not an optional extra.
Charcot's triad has a sensitivity of 26.4 per cent and a specificity of 95.9 per cent. It rules cholangitis in and never rules it out.
Around 80 per cent of patients with organ dysfunction in the Tokyo validation study did not have the full triad. The sickest are the ones who look atypical.
Reynolds' pentad adds hypotension and confusion to the triad, and marks a patient who needs drainage now rather than in the morning.
The Tokyo Guidelines are Japanese, from the Japanese Society of Hepato-Biliary-Pancreatic Surgery. TG18 is the current edition and NICE has not endorsed it.
NICE CG188 dates from 2014. The 2018 surveillance review looked at new evidence on ERCP timing and still decided not to update the guideline.
Gentamicin needs serum concentration monitoring. On multiple daily dosing the trough should be below 2 mg/L and the one-hour peak 5 to 10 mg/L.
Out-of-hours ERCP provision varies across the UK. If your hospital cannot deliver it tonight, the transfer conversation starts now, not at the 24-hour mark.

First-line investigation

Liver function tests and transabdominal ultrasound, alongside blood cultures and a venous gas with lactate; MRCP then endoscopic ultrasound if ultrasound does not explain a dilated duct.

Management

Treat the sepsis and start the clock

ABCDE. Calculate NEWS2 and record the time: the antibiotic clock runs from it. A score of 7 or more with suspected infection is high risk.⁹
Hartmann's 250 mL over 10 to 15 minutes. Reassess. Repeat to a 1000 mL maximum, then senior clinical decision maker.⁹
Broad-spectrum intravenous antibiotics within 1 hour of calculating NEWS2. Blood cultures, venous gas with lactate, FBC, CRP, U&E, creatinine, LFTs and clotting.^9,11
Oxygen to 94 to 98 per cent, or 88 to 92 per cent if at risk of hypercapnic respiratory failure. Telephone gastroenterology or hepatobiliary surgery now.¹¹

The drugs, with doses

BNF biliary-tract regimen: ciprofloxacin, or gentamicin, or a cephalosporin. Ciprofloxacin 400 mg every 8 to 12 hours by intravenous infusion over 60 minutes.^12,13
Gentamicin initially 5 to 7 mg/kg once daily intravenously, adjusted to serum concentration. Ceftriaxone 2 g once daily. Co-amoxiclav 1.2 g every 8 hours.^14,15,16
Morphine 5 mg by slow intravenous injection every 4 hours, reduced in frail or elderly patients. Paracetamol 1 g intravenously every 4 to 6 hours, maximum 4 g daily.^18,19
Local antimicrobial policy governs the final choice. Adjust gentamicin for renal function, use ideal body weight in obesity, and narrow when cultures return.^11,14

Confirm the obstruction and grade the patient

Liver function tests and ultrasound first. MRCP if the duct is dilated or liver tests abnormal without a visible stone; endoscopic ultrasound if MRCP is non-diagnostic.^1,2
TG18 diagnosis: one item from systemic inflammation plus one from cholestasis or imaging is suspected. One from each of the three is definite. Suspected is enough to act.^4,3
Grade III is organ dysfunction: noradrenaline at any dose, reduced consciousness, PaO2/FiO2 below 300, creatinine above 177 micromol/L (2.0 mg/dL), INR above 1.5, or platelets below 100 × 10⁹/L.^3,4
Grade II is any two of: white cells above 12 or below 4 × 10⁹/L, temperature 39°C or above, age 75 or over, bilirubin 85 micromol/L (5 mg/dL) or more, low albumin.^3,4

Drain the duct

Emergency ERCP within 24 hours under NICE QS104 statement 3 when cholangitis is not responding to antibiotics and intravenous fluids, or there is septic shock.^7,2
ERCP within 72 hours under statement 2 for duct stones causing jaundice without that emergency indication. Delay beyond 72 hours raises the vasopressor requirement.^8,2
TG18 wants urgent drainage in Grade III, early drainage in Grade II, and drainage in Grade I only if there is no response to initial treatment.^4,5
If ERCP fails or the anatomy forbids it, percutaneous transhepatic biliary drainage. EUS-guided drainage is a specialised-centre option for distal malignant obstruction only.^10,2,17
Rectal diclofenac or indometacin 100 mg at the time of ERCP for everyone without an NSAID contraindication, to reduce post-ERCP pancreatitis.²

Clear the duct and take the gallbladder

Clear the duct surgically at laparoscopic cholecystectomy, or by ERCP before or at the same operation. A stent is temporary: book the definitive procedure.^1,2
CG188 requires clearance and cholecystectomy for duct stones but sets no interval after cholangitis. The 1 week clock applies to acute cholecystitis, not to this.^1,6

Review and watch

Narrow the antibiotic on culture results once the source is controlled. Give explicit return advice for fever, rigors, pain or jaundice.¹¹
Watch for recurrent obstruction, liver abscess, acute kidney injury, and the ERCP complications: pancreatitis (commonly 2 to 5 per cent), bleeding, perforation and incomplete drainage.²

Exam traps

Absence of jaundice does not exclude cholangitis. The triad is a rule-in test only, and the frail and elderly are the ones who present without it.
ERCP is a treatment, not a diagnostic test. Diagnose with ultrasound, MRCP or endoscopic ultrasound, and never let them delay drainage in a septic patient.
The BNF biliary-tract regimen is ciprofloxacin or gentamicin or a cephalosporin. It does not include metronidazole; add anaerobic cover only on microbiology advice.
The 24-hour standard applies to patients who need emergency ERCP, not to every duct stone. Jaundice without that indication carries the 72-hour standard.
The sepsis fluid bolus is 250 mL, not 500 mL. NICE NG253 changed the sepsis figure in 2025 and the committed sepsis chapters follow it.
Sepsis that persists after adequate antibiotics and fluid is a source-control failure. Escalate for drainage rather than changing the antibiotic.
Urgent ERCP in gallstone disease is for cholangitis or ongoing biliary obstruction, not for uncomplicated gallstone pancreatitis.
A stent placed after failed duct clearance is temporary. Book the definitive clearance before discharge, or it becomes a forgotten stent and a second admission.

Illustrations

MRCP showing choledocholithiasisMRCP demonstrating gallstones and dark filling defects within the distal common bile duct, consistent with choledocholithiasis.Hellerhoff, Wikimedia Commons · CC-BY-SA-3.0

Charcot triad and severe cholangitis warning signsDiagram linking right-upper-quadrant pain, fever/rigors and jaundice with the additional hypotension, confusion and organ dysfunction that indicate severe sepsis and urgent biliary drainage.PassFinals · original

ERCP showing an obstructing common bile duct stoneFluoroscopic ERCP showing cannulation and opacification of the biliary tree with a distal common bile duct filling defect caused by an obstructing stone.Samir, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.