Ascending cholangitis

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

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.

Key points

Ascending cholangitis is infection within an obstructed biliary system; antibiotics penetrate an imperfectly drained source and therefore cannot replace decompression when obstruction persists.
Charcot's triad of right-upper-quadrant pain, fever and jaundice is memorable but incompletely sensitive; absence of one component must not reassure a deteriorating patient.
Hypotension and altered mental state added to the triad form Reynolds' pentad and signal advanced disease, not criteria to wait for before escalating.
Use ABCDE, obtain blood cultures promptly, measure lactate, give oxygen when indicated, restore perfusion carefully and start local-guideline intravenous antibiotics without unnecessary delay.
Contact the emergency endoscopy and senior hepatopancreatobiliary team early; source control is usually ERCP drainage, with percutaneous or surgical routes when endoscopy fails or anatomy prevents it.
Ultrasound, MRCP or CT can demonstrate obstruction, but a septic patient should not wait for a perfect duct map when clinical and biochemical evidence already supports urgent drainage.
Common causes include choledocholithiasis, malignant or benign stricture, blocked stent and postoperative anatomy; definitive treatment continues after the initial pus and pressure are relieved.
Older, frail, immunosuppressed and biliary-stented patients may present with delirium, falls, renal injury or unexplained sepsis rather than dramatic jaundice or local pain.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Common-duct stones

Choledocholithiasis is a frequent cause of infected obstruction, particularly when a stone impacts distally and prevents adequate bile drainage.

Malignant or benign stricture

Pancreaticobiliary cancer, postoperative narrowing, pancreatitis and primary sclerosing cholangitis can obstruct ducts and permit infection above the blockage.

Instrumented biliary system

An occluded or migrated stent, recent ERCP or biliary-enteric anatomy can introduce organisms and prevent free drainage.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Biliary obstruction
Blocked bile flow raises intraductal pressure, impairs local antibacterial defences and causes cholestasis, preventing normal clearance of organisms.
2
Ascending infection
Enteric organisms colonise stagnant bile and spread proximally through the obstructed ductal system, potentially entering the bloodstream under pressure.
3
Biliary sepsis
Rising pressure permits bacteria and endotoxin to enter blood and lymphatics, causing bacteraemia, shock and multiorgan dysfunction.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Inflammation plus cholestasis

Fever, rigors or inflammatory deterioration accompanied by jaundice, dark urine or rising bilirubin and alkaline phosphatase strongly suggests an infected obstructed tree.

Septic shock phenotypeRed flag

Hypotension, mottling, prolonged capillary refill, oliguria, rising lactate, hypoxaemia or confusion marks organ dysfunction and requires emergency senior and critical-care support.

Blocked stent presentationRed flag

Recurrent fever, pain or jaundice after biliary stenting should be treated as possible stent occlusion or migration until imaging and endoscopic review show otherwise.

Muted older presentationRed flag

Delirium, reduced intake, falls, acute kidney injury or functional collapse can dominate in older adults, with little abdominal guarding and only subtle jaundice.

Post-procedure deterioration

Fever and pain following ERCP could reflect cholangitis, pancreatitis, perforation, bleeding or cholecystitis; rapid reassessment must distinguish these dangerous complications.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Repeated physiological observationsFirst step
Why
Detect evolving organ dysfunction and measure response to fluids, antimicrobials and biliary drainage.
Interpretation and limitations
A trend towards hypotension, tachypnoea, oxygen need, delirium or oliguria outweighs a superficially reassuring abdominal examination.
02
Venous or arterial lactate and blood gas
Why
Assess perfusion, acid-base disturbance, ventilation and metabolic deterioration in a systemically unwell patient.
Interpretation and limitations
Raised or rising lactate supports high-risk sepsis but normal lactate does not exclude severe local obstruction or early organ injury.
03
Blood cultures and infection screen
Why
Recover causative organisms and identify simultaneous urinary, pulmonary, line or other sources before narrowing therapy.
Interpretation and limitations
Culture positivity supports bloodstream spread and informs de-escalation; sampling should precede antibiotics only when it can be completed immediately.
04
Liver, renal, clotting and inflammatory profiles
Why
Demonstrate cholestasis, grade organ injury and prepare for contrast, sedation and intervention.
Interpretation and limitations
Bilirubin may lag or fluctuate. Thrombocytopenia, INR prolongation and acute kidney injury increase procedural and critical-care complexity.
05
Urgent biliary ultrasound
Why
Look for duct dilatation, gallbladder stones and a proximal mechanical cause at the bedside or radiology department.
Interpretation and limitations
Dilatation reinforces obstruction, but early stone disease or a dysfunctional stent can be dangerous without striking calibre change.
06
CT or MRCP selected by stability
Why
Define level, cause, abscess, tumour and altered anatomy when cross-sectional mapping will change the drainage plan.
Interpretation and limitations
MRCP is detailed but slower and non-therapeutic; CT may better assess competing abdominal sepsis. Neither should postpone indicated source control.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Acute cholecystitis

Focal right-upper-quadrant tenderness and gallbladder inflammation without jaundice or common-duct obstruction favour isolated cholecystitis on initial assessment.

Acute hepatitis

Marked hepatocellular enzyme elevation, viral or toxic exposure and absence of duct dilatation favour hepatitis, though early obstruction may transiently mimic it.

Gallstone pancreatitis

Back-radiating epigastric pain and diagnostic pancreatic enzyme elevation indicate pancreatitis; concurrent cholangitis remains possible when obstruction and sepsis persist.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01First hourSepsis and obstruction responseFirst stepBiliary symptoms, inflammation and cholestasis occur with systemic illness or organ dysfunction.

1Start ABCDE, call senior help, give oxygen for hypoxaemia, establish intravenous access and monitor urine output and mental state.
2Obtain cultures and core blood tests promptly, then administer the locally recommended intravenous biliary-sepsis regimen with renal and allergy adjustment.
3Resuscitate hypoperfusion using repeated clinical reassessment, avoiding both inadequate restoration and unmonitored fluid overload in cardiac or renal vulnerability.
4Alert ERCP, HPB surgery, anaesthesia and critical care early, communicating suspected level, previous anatomy, anticoagulation and any existing stent.

02DrainUrgent biliary source controlCholangitis is suspected and obstruction persists, especially with physiological deterioration.

1Use the fastest imaging that materially aids safe access, without waiting for sequential diagnostic tests in an unstable patient.
2Perform ERCP drainage through an experienced service when feasible; limit the first procedure to reliable decompression if complex extraction would be unsafe.
3Use percutaneous transhepatic or surgical drainage when endoscopic access fails, is unavailable in the required timeframe or altered anatomy prevents cannulation.
4Send bile or device cultures when obtained, document achieved segments and reassess immediately if fever, bilirubin or organ function fails to improve.

03AftercarePrevent the next obstructionThe patient has stabilised after drainage and the acute infection is resolving.

1Review cultures, narrow antibiotics and agree duration based on source control, bloodstream infection and local antimicrobial policy.
2Complete stone clearance or stricture investigation through the HPB team, obtaining staging imaging before further instrumentation when cancer is possible.
3DefinitiveArrange laparoscopic cholecystectomy after gallstone-source disease when suitable, rather than treating successful ERCP as definitive gallbladder care.
4Enter all stents into a recall system and teach the patient or carers that recurrent fever or jaundice requires urgent assessment.

Key medicines and prescribing safety3 treatments · regimens, roles and cautions

Treats Gram-negative and other likely biliary pathogens while urgent decompression is organised.

Empiric intravenous cholangitis antibiotics

Administer the current trust biliary-sepsis regimen promptly at BNF doses, adjusting for kidney function, body size, allergy and resistant-organism history.

Selection varies by local resistance and healthcare exposure; obtain cultures where immediate, review daily and never allow repeat dosing to postpone drainage.

Restores intravascular volume during septic vasodilatation, vomiting or poor intake before vasopressor escalation when required.

Balanced or isotonic crystalloid

Give protocol-sized intravenous boluses only for evidence of hypoperfusion, reassessing blood pressure, lungs, urine output, lactate and peripheral perfusion after each.

Fixed large volumes can harm frail patients or those with heart, kidney or liver failure; shock refractory to cautious resuscitation needs critical-care vasopressors.

Supports arterial pressure when septic shock persists despite appropriate initial volume assessment and source-control mobilisation.

Noradrenaline in critical care

Use a titrated continuous infusion through the local septic-shock protocol with appropriate vascular access and invasive monitoring.

This is a critical-care medicine, not a substitute for decompression; extravasation, arrhythmia and limb or gut ischaemia require vigilance.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Septic shock

Uncontrolled infected obstruction causes vasodilatation, hypotension, rising lactate and multiorgan failure unless resuscitation and biliary decompression occur promptly.

Acute kidney and coagulation injury

Sepsis, hypovolaemia and cholestasis can cause renal dysfunction, thrombocytopenia and impaired coagulation, increasing procedural risk during intervention.

Hepatic abscess and recurrent infection

Persistent infected bile may seed focal liver collections, while an unresolved stone, stricture or unowned stent predisposes to repeated episodes.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Record frequent NEWS2 components plus urine output, capillary refill, mental state and analgesic or sedative exposure during the unstable phase.
Repeat lactate and renal, liver, coagulation and inflammatory profiles according to severity and after drainage.
Check for ERCP pancreatitis, bleeding, perforation, aspiration and continuing cholangitis before apparent post-sedation drowsiness is accepted.
Review microbiology every day, including bile cultures, and document the justification for continuing broad-spectrum therapy.
Audit device follow-up by confirming stent exchange or removal rather than merely issuing an appointment request.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Triads miss patients

The classic teaching aid is specific when complete but insufficiently sensitive for safe exclusion, especially in frailty.

Drainage can be staged

In shock, a simple stent or nasobiliary drain may be safer than prolonged attempts at complete calculus extraction.

A quiet abdomen deceives

Systemic infection can be severe despite limited tenderness because the infected compartment lies within the biliary tree.

Segments can remain blocked

Hilar obstruction may require deliberate selection of which liver sector to drain; indiscriminate contrast injection can contaminate undrained ducts.

Recurrent sepsis has hardware

Always ask when a biliary stent was inserted and when it was meant to be exchanged or removed.

11Common pitfallsFrequent interpretation and management errors.

01
Waiting for all five Reynolds features before declaring an emergency.
02
Repeatedly prescribing broader antibiotics without obtaining biliary decompression.
03
Allowing MRCP scheduling to delay drainage in evolving septic shock.
04
Assuming normal duct calibre excludes an occluded stent or migrating calculus.
05
Attempting prolonged definitive stone clearance in a profoundly unstable patient.
06
Forgetting cholecystectomy or stent recall after successful acute treatment.