Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Identify infected biliary obstruction before shock develops, deliver immediate sepsis treatment and coordinate urgent decompression while preserving a plan for the underlying cause.
Bile is normally protected by flow, the sphincter mechanism and antimicrobial properties. Obstruction raises intraductal pressure, permits bacterial ascent and can drive organisms or endotoxin into the bloodstream. Stones are common, but cancer, strictures, parasites in relevant travel settings, surgical injury and occluded prostheses also cause the combination. Once organ dysfunction appears, mortality risk depends on speed of resuscitation and drainage rather than on completion of a classic symptom triad.
Diagnosis is clinical and anatomical. Fever or rigors, inflammatory markers and cholestatic liver tests support infection with obstruction. Ultrasound can show duct dilatation and gallstones; CT assesses complications and other sepsis sources; MRCP maps level and cause in a stable patient. None of these tests should become a barrier to emergency consultation. A non-dilated duct does not eliminate early obstruction, particularly with a small migrating stone or indwelling stent.
Care proceeds in parallel: stabilise circulation and organs, deliver empiric antimicrobials based on the local biliary-sepsis policy, and obtain biliary source control. ERCP can drain with extraction, sphincterotomy, nasobiliary catheter or stent according to anatomy and stability. In very sick patients the immediate aim may be drainage alone, leaving complex clearance for a later session. Post-procedure ownership must include antibiotic review, device recall, gallbladder surgery when appropriate and cancer or stricture work-up.
Choledocholithiasis is a frequent cause of infected obstruction, particularly when a stone impacts distally and prevents adequate bile drainage.
Pancreaticobiliary cancer, postoperative narrowing, pancreatitis and primary sclerosing cholangitis can obstruct ducts and permit infection above the blockage.
An occluded or migrated stent, recent ERCP or biliary-enteric anatomy can introduce organisms and prevent free drainage.
Blocked bile flow raises intraductal pressure, impairs local antibacterial defences and causes cholestasis, preventing normal clearance of organisms.
Enteric organisms colonise stagnant bile and spread proximally through the obstructed ductal system, potentially entering the bloodstream under pressure.
Rising pressure permits bacteria and endotoxin to enter blood and lymphatics, causing bacteraemia, shock and multiorgan dysfunction.
Fever, rigors or inflammatory deterioration accompanied by jaundice, dark urine or rising bilirubin and alkaline phosphatase strongly suggests an infected obstructed tree.
Hypotension, mottling, prolonged capillary refill, oliguria, rising lactate, hypoxaemia or confusion marks organ dysfunction and requires emergency senior and critical-care support.
Recurrent fever, pain or jaundice after biliary stenting should be treated as possible stent occlusion or migration until imaging and endoscopic review show otherwise.
Delirium, reduced intake, falls, acute kidney injury or functional collapse can dominate in older adults, with little abdominal guarding and only subtle jaundice.
Fever and pain following ERCP could reflect cholangitis, pancreatitis, perforation, bleeding or cholecystitis; rapid reassessment must distinguish these dangerous complications.
Focal right-upper-quadrant tenderness and gallbladder inflammation without jaundice or common-duct obstruction favour isolated cholecystitis on initial assessment.
Marked hepatocellular enzyme elevation, viral or toxic exposure and absence of duct dilatation favour hepatitis, though early obstruction may transiently mimic it.
Back-radiating epigastric pain and diagnostic pancreatic enzyme elevation indicate pancreatitis; concurrent cholangitis remains possible when obstruction and sepsis persist.
Uncontrolled infected obstruction causes vasodilatation, hypotension, rising lactate and multiorgan failure unless resuscitation and biliary decompression occur promptly.
Sepsis, hypovolaemia and cholestasis can cause renal dysfunction, thrombocytopenia and impaired coagulation, increasing procedural risk during intervention.
Persistent infected bile may seed focal liver collections, while an unresolved stone, stricture or unowned stent predisposes to repeated episodes.
The classic teaching aid is specific when complete but insufficiently sensitive for safe exclusion, especially in frailty.
In shock, a simple stent or nasobiliary drain may be safer than prolonged attempts at complete calculus extraction.
Systemic infection can be severe despite limited tenderness because the infected compartment lies within the biliary tree.
Hilar obstruction may require deliberate selection of which liver sector to drain; indiscriminate contrast injection can contaminate undrained ducts.
Always ask when a biliary stent was inserted and when it was meant to be exchanged or removed.
Waiting for all five Reynolds features before declaring an emergency.
Repeatedly prescribing broader antibiotics without obtaining biliary decompression.
Allowing MRCP scheduling to delay drainage in evolving septic shock.
Assuming normal duct calibre excludes an occluded stent or migrating calculus.
Attempting prolonged definitive stone clearance in a profoundly unstable patient.
Forgetting cholecystectomy or stent recall after successful acute treatment.
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A jaundiced patient has fever, rigors, hypotension and confusion with an obstructed common bile duct on ultrasound. Antibiotics and initial resuscitation have begun. What is the most important next definitive action?
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
Selection varies by local resistance and healthcare exposure; obtain cultures where immediate, review daily and never allow repeat dosing to postpone drainage.
Fixed large volumes can harm frail patients or those with heart, kidney or liver failure; shock refractory to cautious resuscitation needs critical-care vasopressors.
This is a critical-care medicine, not a substitute for decompression; extravasation, arrhythmia and limb or gut ischaemia require vigilance.