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.
- 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.
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.
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.
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.
- Resuscitate hypoperfusion using repeated clinical reassessment, avoiding both inadequate restoration and unmonitored fluid overload in cardiac or renal vulnerability.
- Alert ERCP, HPB surgery, anaesthesia and critical care early, communicating suspected level, previous anatomy, anticoagulation and any existing stent.