Synopsis
Identify infected biliary obstruction before shock develops, deliver immediate sepsis treatment and coordinate urgent decompression while preserving a plan for the underlying cause.
- 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.
Key red flags
Hypotension, mottling, prolonged capillary refill, oliguria, rising lactate, hypoxaemia or confusion marks organ dysfunction and requires emergency senior and critical-care support.
Investigation priorities
Detect evolving organ dysfunction and measure response to fluids, antimicrobials and biliary drainage.
Management branches
Biliary symptoms, inflammation and cholestasis occur with systemic illness or organ dysfunction.
- Start ABCDE, call senior help, give oxygen for hypoxaemia, establish intravenous access and monitor urine output and mental state.
- Obtain cultures and core blood tests promptly, then administer the locally recommended intravenous biliary-sepsis regimen with renal and allergy adjustment.
Key medicines
Empiric intravenous cholangitis antibioticsAdminister the current trust biliary-sepsis regimen promptly at BNF doses, adjusting for kidney function, body size, allergy and resistant-organism history.
Balanced or isotonic crystalloidGive protocol-sized intravenous boluses only for evidence of hypoperfusion, reassessing blood pressure, lungs, urine output, lactate and peripheral perfusion after each.