Synopsis
Recognise biliary and intra-abdominal sepsis early, stabilise organ dysfunction, choose anatomy-directed imaging and achieve timely endoscopic, radiological or surgical source control.
- Acute cholangitis is infection behind an obstructed biliary tree; antibiotics cannot reliably sterilise a pressurised system without drainage.
- Charcot triad is fever, jaundice and right upper-quadrant pain, but its absence does not exclude cholangitis.
- Take blood cultures before antibiotics when this does not delay treatment; bacteraemia is common and guides de-escalation.
Key red flags
Hypotension, rising lactate, confusion or oliguria indicates sepsis-related organ dysfunction.
Fever or rigors, jaundice and right upper-quadrant or epigastric pain support cholangitis, although older or immunocompromised adults may lack the full triad.
Investigation priorities
Identify bacteraemia and susceptibility while preserving diagnostic yield.
Management branches
Biliary or intra-abdominal infection is accompanied by abnormal physiology or organ dysfunction.
- Use ABCDE, measure lactate and glucose, secure intravenous access, monitor urine output and give oxygen and balanced crystalloid according to physiology.
- Obtain blood cultures promptly and begin intravenous antimicrobials within the sepsis pathway, adjusted for allergy, renal function, recent cultures and healthcare exposure.
Key medicines
Co-amoxiclav intravenous regimenGive 1.2 g intravenously every eight hours only when the local intra-abdominal guideline selects it, with renal adjustment as required.
Cefuroxime plus metronidazoleWhere locally recommended, give cefuroxime 1.5 g intravenously every eight hours plus metronidazole 500 mg intravenously every eight hours.