Cholangitis (Bile Duct Infection)

What cholangitis is

Bile is made in the liver and flows through the bile ducts to the small intestine, passing the gallbladder on the way. When the main bile duct (common bile duct) is blocked, bile backs up and pressure rises. Bacteria from the intestine travel up the duct and multiply in the stagnant bile. Under high pressure, bacteria and toxins enter the bloodstream, which is why cholangitis can quickly cause sepsis.

The word "cholangitis" is also used in the names of two long-term autoimmune liver conditions, primary sclerosing cholangitis and primary biliary cholangitis. These cause chronic inflammation and scarring of the bile ducts and are managed differently. This page focuses on acute infection.

Symptoms

Charcot's triad

1. fever, often with shaking chills (rigors)
2. jaundice: yellow skin and eyes
3. pain in the upper right belly

All three occur together in about half to three quarters of people.

Reynolds' pentad

Charcot's triad plus confusion and low blood pressure. This signals severe infection with septic shock and needs immediate intensive treatment.

Other symptoms

• dark, tea-colored urine
• pale, clay-colored stools
• itching
• nausea and vomiting
• in older adults, confusion or general weakness may be the only signs

Causes

Diagnosis

Doctors use the Tokyo Guidelines, which combine:

• signs of inflammation: fever, raised white blood cell count, raised CRP
• cholestasis: jaundice, raised bilirubin, abnormal liver enzymes (alkaline phosphatase, GGT)
• imaging: a dilated bile duct or a visible stone, stricture or stent on scans

Tests include:

• blood tests: complete blood count, liver function, kidney function, lactate, clotting, blood cultures
• abdominal ultrasound: first test, shows gallstones and duct dilation
• CT scan: especially when cancer is possible
• MRCP: an MRI of the bile ducts, to see stones or strictures without instruments
• endoscopic ultrasound: a very sensitive test for small duct stones

Severity is graded as mild (grade I), moderate (grade II) or severe (grade III, with organ dysfunction).

Treatment

Antibiotics and support

• Intravenous antibiotics started as soon as cholangitis is suspected, chosen to cover gut bacteria, then adjusted to blood culture results. Typical courses are 4 to 7 days after the source is controlled.
• Intravenous fluids, pain relief, and treatment of low blood pressure. Severe cases are managed in intensive care.

Draining the bile duct

The blockage must be relieved. Timing depends on severity: urgently (within hours to a day) for moderate and severe cholangitis, and within a few days for mild cases that respond to antibiotics.

• ERCP (endoscopic retrograde cholangiopancreatography): a flexible scope passed through the mouth into the duodenum. The doctor cuts the opening of the duct (sphincterotomy), removes stones, and places a stent if needed. It is the first-choice drainage method.
• Percutaneous transhepatic biliary drainage: a tube placed through the skin into the liver ducts when ERCP is not possible.
• Surgery: rarely needed for drainage now.

Preventing recurrence

• Gallbladder removal (cholecystectomy) is recommended after gallstone cholangitis, ideally during the same hospital stay or soon after, to prevent further stones.
• Stents are replaced on schedule.
• Strictures and tumors are treated according to cause.

Complications

• sepsis and septic shock
• liver abscess
• acute kidney injury
• pancreatitis from a stone or after ERCP
• recurrent cholangitis

Severe untreated cholangitis has a high death rate. With prompt antibiotics and drainage, most people recover well.

Frequently asked questions

What are the symptoms of cholangitis?

The classic symptoms are fever with chills, yellowing of the skin and eyes, and pain in the upper right belly, known as Charcot's triad. Dark urine, pale stools, itching and nausea are common. Confusion and low blood pressure indicate a life-threatening infection.

What causes cholangitis?

Acute cholangitis is caused by bacteria infecting bile that is trapped behind a blockage in the bile duct. Gallstones are the most common cause. Narrowing from surgery or inflammation, tumors and blocked stents are other causes.

Is cholangitis an emergency?

Yes. Acute cholangitis can lead to sepsis within hours. Anyone with fever, jaundice and upper right belly pain should go to the ER. Treatment with intravenous antibiotics and bile duct drainage is lifesaving.

How is cholangitis treated?

Treatment combines intravenous antibiotics and fluids with draining the blocked bile duct, usually by ERCP to remove stones or place a stent. If gallstones were the cause, the gallbladder is usually removed afterward to prevent recurrence.

What is the difference between cholangitis and cholecystitis?

Cholangitis is infection of the bile ducts, usually from a blocked common bile duct, and typically causes jaundice. Cholecystitis is inflammation of the gallbladder itself, usually from a stone blocking its outlet, causing right upper belly pain and fever, often without jaundice.