Acute Cholangitis

How cholangitis develops

Bile flows continuously from the liver through the bile ducts into the duodenum. When a duct is blocked, pressure builds and bacteria from the gut climb up into the stagnant bile (hence "ascending" cholangitis). As pressure rises, bacteria and their toxins pass into the bloodstream, which is why cholangitis can turn into sepsis quickly.

Common bacteria include E. coli, Klebsiella and Enterococcus, and sometimes anaerobes.

Causes

• Gallstones in the common bile duct (choledocholithiasis): the most common cause, especially in older adults.
• Bile duct strictures after surgery, chronic pancreatitis or primary sclerosing cholangitis.
• Tumors of the pancreas, bile ducts or ampulla that block the duct.
• Blocked biliary stents placed for previous blockages.
• After procedures such as ERCP.
• Parasites such as liver flukes, in some parts of the world.

Risk factors include known gallstones, age over 50, previous bile duct surgery and bile duct stents.

Symptoms

Charcot's triad is the classic picture:

1. Fever, often with rigors (shaking chills)
2. Jaundice: yellow skin and eyes, dark urine and pale stools
3. Right upper abdominal pain

Only about half of patients have all three. Reynolds' pentad adds confusion and low blood pressure, signs of severe disease and septic shock. Older adults may have only confusion or low blood pressure.

Diagnosis

The Tokyo Guidelines combine three groups of findings:

• Signs of inflammation: fever, chills, high white blood cell count or raised C-reactive protein.
• Signs of blocked bile flow: jaundice and abnormal liver tests (raised bilirubin, alkaline phosphatase, GGT and liver enzymes).
• Imaging: a widened bile duct, or a visible cause such as a stone, stricture or stent.

Tests usually include blood counts, liver and kidney function, lactate, blood cultures, and imaging:

• Abdominal ultrasound: first-line, showing gallstones and duct widening.
• CT scan: helpful in very unwell patients and to look for tumors or complications.
• MRCP: an MRI of the bile ducts that shows stones and strictures without a scope.
• Endoscopic ultrasound: for small stones.

Severity grading

Treatment

Supportive care and antibiotics

• IV fluids to treat dehydration and low blood pressure
• IV antibiotics covering gut bacteria, started promptly after blood cultures
• Pain relief and anti-sickness medicine
• Intensive care support if there is organ failure

Bile duct drainage

Relieving the blockage is the key treatment:

• ERCP (endoscopic retrograde cholangiopancreatography): a flexible camera is passed through the mouth to the duodenum. The bile duct opening is widened (sphincterotomy), stones are removed with a balloon or basket, and a stent may be placed to keep bile flowing. It is the first-choice method.
• Percutaneous transhepatic biliary drainage (PTBD): a tube is placed into the bile ducts through the skin when ERCP is not possible.
• EUS-guided drainage: an option in specialist centers.
• Surgical drainage is rarely needed today.

Preventing recurrence

After cholangitis from gallstones, gallbladder removal (cholecystectomy) is usually recommended, ideally during the same admission or within a few weeks, to prevent further stones and attacks. Strictures and tumors need specific treatment.

Complications

• Sepsis and septic shock
• Liver abscess
• Acute kidney injury
• Acute pancreatitis, from a stone or ERCP
• Recurrent cholangitis if the cause is not addressed

Outlook

With antibiotics and timely drainage, most people recover well, usually within days. Mortality has fallen sharply since ERCP became widely available, but severe cholangitis in older adults with other illnesses still carries significant risk, which is why fast recognition matters.

Frequently asked questions

What are the symptoms of acute cholangitis?

The classic symptoms are fever with chills, yellow skin or eyes, and pain in the upper right abdomen. Dark urine and pale stools are common. Severe cases cause confusion and low blood pressure. Older adults may have few typical symptoms.

What is Charcot's triad?

Charcot's triad is the combination of fever, jaundice and right upper abdominal pain, the classic signs of acute cholangitis. Adding confusion and low blood pressure gives Reynolds' pentad, which signals severe cholangitis with sepsis.

Is acute cholangitis an emergency?

Yes. It can lead to sepsis and organ failure within hours. Anyone with fever, jaundice and upper right abdominal pain should go to the ER. Treatment with IV antibiotics and drainage of the bile duct is needed promptly.

How is acute cholangitis treated?

It is treated with IV fluids, antibiotics, and drainage of the blocked bile duct, usually by ERCP, which removes stones and can place a stent. Afterward, gallbladder removal is often recommended to prevent recurrence.

What is the difference between cholangitis and cholecystitis?

Cholangitis is infection of the bile ducts, usually from a stone blocking the common bile duct, and typically causes jaundice. Cholecystitis is inflammation of the gallbladder from a stone blocking its outlet, usually without jaundice. Both cause right upper abdominal pain and fever.