Bedside Rounds

Acute cholangitis and choledocholithiasis: workup and management

Acute cholangitis is biliary obstruction with infection: fever, jaundice and RUQ pain (Charcot triad), with shock and confusion in severe cases. Grade severity (Tokyo 2018), give antibiotics, resuscitate, and arrange biliary drainage, usually ERCP, within 24–48 hours depending on severity.

Working diagnosis Adult · US guidelines Draft · awaiting physician review
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01Orient

What's new in the evidence

  • ASGE 2021 cholangitis guideline: ERCP within 48 hours for most, sooner (<24 h) in septic shock; aim for stone clearance rather than stent alone when feasible
  • Short antibiotic courses after successful drainage: 4 days was noninferior to 8 days in moderate–severe cholangitis (RCT 2024)
  • Same-admission cholecystectomy after gallstone cholangitis is increasingly supported

Differential diagnoses

  1. Acute cholangitis from choledocholithiasis
  2. Malignant biliary obstruction (pancreatic head, cholangiocarcinoma, ampullary)
  3. Stent occlusion
  4. Acute cholecystitis, Mirizzi syndrome
  5. Liver abscess
  6. Pancreatitis, hepatitis

02Assess

Risk scores and decision tools

  • Tokyo Guidelines 2018 diagnostic criteria and severity grade (I mild, II moderate, III severe)
  • ASGE risk of choledocholithiasis (high, intermediate, low) to choose ERCP, MRCP/EUS or cholecystectomy
  • SOFA for organ dysfunction

Key history questions

  • Fever, rigors, jaundice, RUQ pain, dark urine, pale stools
  • Prior gallstones, cholecystectomy, biliary stents or ERCP
  • Weight loss, painless jaundice (malignancy)
  • Anticoagulants and antiplatelets (before ERCP)
  • Recent antibiotics or healthcare exposure

Examination findings

  • Fever, hypotension, tachycardia, confusion (Reynolds pentad)
  • Jaundice, RUQ tenderness
  • Palpable gallbladder (Courvoisier sign suggests malignancy)

03Investigate

Initial investigations

  • CBC, CMP (bilirubin, ALP, GGT, AST/ALT), lipase, lactate
  • Blood cultures before antibiotics
  • Coagulation (INR) before ERCP
  • RUQ ultrasound: dilated ducts, stones

Advanced investigations

  • MRCP or EUS for intermediate probability of duct stones
  • CT abdomen if malignancy, abscess or complications suspected
  • Bile culture at ERCP

04Treat

Immediate management

  • Antibiotics within 1 hour if septic: piperacillin-tazobactam, or ceftriaxone plus metronidazole; cefepime or meropenem plus metronidazole if healthcare-associated or severe
  • Fluid resuscitation and vasopressors as needed
  • Severe (grade III): urgent biliary drainage within 24 hours once stabilized

First-line treatment

  • ERCP with sphincterotomy and stone extraction within 48 hours for grade I–II
  • Percutaneous transhepatic biliary drainage if ERCP fails or is not possible
  • Antibiotics for 4–7 days after source control (longer if bacteremia with gram-positive organisms or undrained collections)

Second-line treatment

  • Cholecystectomy during the same admission for gallstone disease once recovered
  • Malignant obstruction: drainage, then oncology and surgical evaluation

Specialist referrals

  • Gastroenterology for ERCP
  • Interventional radiology for PTBD
  • General surgery for cholecystectomy
  • ICU for severe cholangitis

05Disposition

Admission criteria

  • All acute cholangitis
  • Grade III or shock: ICU

Safe discharge criteria

  • Drainage achieved, afebrile, eating, labs improving
  • Cholecystectomy done or scheduled

Follow-up timing

  • Surgical follow-up for cholecystectomy if not done
  • LFTs in 1–2 weeks

Patient instructions

  • Return for fever, jaundice or abdominal pain

Monitoring

  • Vitals, lactate, bilirubin trend
  • Blood culture results to narrow antibiotics

Clinical pearls and pitfalls

  • Antibiotics without drainage fail in moderate–severe cholangitis
  • Older adults may lack fever or pain
  • Hold or reverse anticoagulation for sphincterotomy per endoscopist

RefGuidelines and landmark evidence

For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.

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