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.
- Ultrasound is the usual initial biliary imaging test in a stable patient; CT better assesses perforation, abscess and alternative intra-abdominal sources.
- Severe cholangitis requires urgent endoscopic or alternative biliary decompression coordinated with resuscitation and critical care.
- Empirical antimicrobial choice is local because resistance, prior instrumentation, allergy and organ function materially alter safe coverage.
- Perforation, anastomotic leak, devitalised bowel and abscess require prompt surgical or radiological source control rather than prolonged antibiotics alone.
- Review antimicrobial therapy at 48 to 72 hours against cultures, procedure findings and adequacy of drainage.
Key red flags
Hypotension, rising lactate, confusion or oliguria indicates sepsis-related organ dysfunction.
Generalised guarding, rigidity or free intraperitoneal gas suggests perforation requiring immediate surgical assessment.
Jaundice with fever and right upper-quadrant pain suggests acute cholangitis from biliary obstruction.
Jaundice, sepsis, hypotension and altered consciousness indicates severe cholangitis requiring urgent drainage.
Persistent sepsis despite antimicrobial therapy suggests failed source control, resistant organisms or an alternative diagnosis.
Fever or rigors, jaundice and right upper-quadrant or epigastric pain support cholangitis, although older or immunocompromised adults may lack the full triad.
Hypotension, confusion, hypoxaemia, oliguria, coagulopathy or thrombocytopenia indicates organ dysfunction and demands urgent decompression and critical-care assessment.
Involuntary guarding, rebound, rigidity, absent bowel sounds or pain worsened by movement suggests contamination, perforation or ischaemia.
ERCP, biliary stent, abdominal surgery, drain manipulation or transplantation changes anatomy, organism probability and the urgency of specialist source control.
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.
- Request early senior, surgical or gastroenterology review and involve critical care for persistent hypotension, rising lactate or respiratory compromise.
- Reassess after every intervention and document the suspected anatomical source, planned imaging and latest acceptable time for drainage or operation.