01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Ascending cholangitis occurs when bacteria infect bile above an obstruction. Gallstones are common causes, but malignant strictures, blocked stents and postoperative narrowing also matter. Raised duct pressure drives bacteria and inflammatory mediators into the circulation, so organ failure may develop quickly. The traditional Charcot triad is neither sufficiently sensitive nor a safe prerequisite for action; older or immunosuppressed adults may present with delirium or hypotension before fever.
Assessment establishes sepsis severity and the anatomy causing it. Ask about prior ERCP, biliary stents, altered surgical anatomy, malignancy and recent antibiotics. Examine perfusion, mental state and abdomen, looking for other infection sources. Liver tests and ultrasound can demonstrate cholestasis and dilatation, while CT or MRCP may map a lesion in stable patients. In severe disease, complex imaging must not delay a practical route to decompression.
Treatment has two inseparable components. Antimicrobials reduce circulating and ductal bacteria; drainage lowers infected pressure and restores flow. ERCP can perform sphincter therapy, extract stones or place a stent. If the papilla is inaccessible or cannulation fails, percutaneous drainage or surgery may be required. Definitive treatment follows recovery: gallbladder removal for a stone source, stent exchange or removal, and tissue diagnosis and oncology planning for malignant obstruction. RCHT specifies drainage within 24 hours for severe disease and within 48 hours for moderate disease; mild disease is drained early if it fails to respond and electively if it responds.
Key points
- Suspect cholangitis from systemic inflammation plus evidence of biliary obstruction; fever, pain and jaundice are helpful but not required together.
- Grade severity while mobilising source control. The current RCHT adult pathway specifies drainage within 24 hours for severe cholangitis and within 48 hours for moderate disease.
- Take cultures first only if this causes no material delay; under NICE NG253, a high-risk adult receives broad-spectrum intravenous antibiotics within one hour of the initial emergency-department NEWS2 score or ward deterioration.
- For hypoperfusion requiring fluid under NG253, give 250 mL balanced isotonic crystalloid over 10–15 minutes, reassess, and repeat 250 mL boluses only if needed to a total 1,000 mL, watching closely for overload.
- Arrange urgent drainage for severe illness or continuing obstruction, most often by therapeutic ERCP, with percutaneous or operative alternatives when endoscopy is unavailable or fails.
- After decompression, confirm physiological and biochemical improvement and create a definitive plan for stones, strictures, tumour or stent management.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Stone obstruction
A common-duct calculus blocks flow and permits bacteria to ascend from the duodenum, making choledocholithiasis a frequent acute cause.
Stricture or device
Malignant or benign narrowing, blocked stents and postoperative anastomotic disease create stagnant infected bile and may require complex drainage.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Pressure-driven infection
Obstruction raises intraductal pressure, impairs local defences and facilitates movement of organisms and toxins into blood.
- 2Systemic inflammatory response
Bacteraemia and mediator release cause vasodilatation, capillary leak and organ dysfunction that can progress despite modest abdominal findings.
- 3Relief by decompression
Restoring bile flow reduces pressure and bacterial burden, allowing antibiotics and immune clearance to become effective.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
The absence of pain, fever or visible jaundice does not exclude cholangitis when inflammatory physiology and cholestasis coexist.
Hypotension, altered mental state, tachypnoea and oliguria identify immediate risk and take priority over perfect anatomical classification.
A person with a biliary stent and new rigors may have occlusion or migration and needs urgent imaging and endoscopy review.
Cholangitis may be the first acute presentation of a pancreaticobiliary tumour or may complicate an existing cancer stent.
Recent ERCP or biliary surgery changes likely anatomy and organisms and can complicate access for repeat drainage.
05InvestigationsWhat to request, why it matters and how to interpret it.
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
Blood culturesFirst step - Why
- Identify bacteraemia and guide narrowed treatment.
- Interpretation and limitations
- Draw promptly from separate sites before antibiotics when this does not delay therapy. Negative cultures do not exclude an infected closed biliary system.
- 02
Liver and organ-function blood tests - Why
- Demonstrate cholestasis and detect renal, hepatic or coagulation dysfunction.
- Interpretation and limitations
- Bilirubin and alkaline phosphatase support obstruction; creatinine, platelets, INR and lactate contribute to severity and procedural planning.
- 03
Ultrasound - Why
- Look rapidly for duct dilatation, gallstones and gallbladder disease.
- Interpretation and limitations
- A dilated duct supports obstruction, but early or distal obstruction can exist without dilatation and bowel gas may obscure stones.
- 04
CT or MRCP - Why
- Map level and cause of obstruction when the patient is stable enough.
- Interpretation and limitations
- These tests can reveal stones, tumour or abscess, but neither drains infected bile; severe deterioration shifts priority to intervention.
- 05
ERCP cholangiography and bile culture - Why
- Define and treat obstruction in one procedure.
- Interpretation and limitations
- Drainage can precede complete stone clearance in an unstable patient. Bile cultures refine antibiotics, while post-ERCP pain or instability requires complication review.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Acute cholecystitis
Gallbladder inflammation causes focal pain and fever, while prominent cholestasis and duct dilatation favour additional common-duct disease.
Acute hepatitis
Hepatocellular injury can cause jaundice and systemic symptoms but does not usually create an obstructed dilated duct requiring drainage.
Non-biliary sepsis
Pneumonia, urinary infection and other sources may coexist with chronic cholestasis; examine the whole patient and interpret imaging temporally.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Worked case: septic obstructive jaundiceDrain while resuscitatingFirst stepA 72-year-old with fever, jaundice and right-upper-quadrant pain becomes confused and hypotensive; blood tests show cholestasis and ultrasound shows a dilated common duct.+
- 1Recognise severe ascending cholangitis with organ dysfunction and call emergency senior, endoscopy, anaesthetic and critical-care support.
- 2Obtain blood cultures rapidly and calculate NEWS2. Because this adult is high risk, give broad-spectrum intravenous antibiotics within one hour; for hypoperfusion needing fluid, give 250 mL balanced crystalloid over 10–15 minutes, reassess perfusion and lungs, and repeat 250 mL boluses only if needed up to 1,000 mL.
- 3EscalationArrange biliary drainage within 24 hours for severe cholangitis, usually by ERCP; if timely competent ERCP cannot be delivered, escalate immediately to percutaneous drainage, while organ support continues.
- 4DefinitiveVerify success through improved blood pressure, consciousness, capillary refill, urine output and lactate, without pulmonary overload; then trend bilirubin and document definitive treatment of the obstruction.
02Failed endoscopic accessChoose another routeERCP cannot cannulate an obstructed duct and the patient remains septic.+
- 1Treat failed access as an unresolved source-control problem rather than a completed procedure.
- 2Discuss percutaneous transhepatic drainage with interventional radiology and operative options with HPB surgery.
- 3Continue organ support and culture-directed antimicrobial review during transfer or intervention.
- 4AlternativeConfirm drain position, output and physiological response after the alternative procedure.
03Recovery after stone drainagePrevent recurrenceERCP drains pus and removes a common-duct stone; the gallbladder contains further stones.+
- 1Review blood and bile cultures after decompression and narrow therapy; RCHT recommends 4–7 days after source control, with longer treatment for specified Gram-positive bacteraemia rather than by default.
- 2Arrange laparoscopic cholecystectomy at the appropriate early opportunity when fit.
- 3Check for temporary biliary stents and book removal or exchange before discharge.
- 4Give clear advice about recurrent fever, jaundice or pain and assign ownership of pending results.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Co-amoxiclav for acute cholangitis: current DBTH adult example
For an adult covered by the Doncaster and Bassetlaw Teaching Hospitals September 2025 protocol, give co-amoxiclav 1.2 g intravenously every 8 hours. Review at 48–72 hours and, once improving after biliary drainage and able to absorb tablets, switch to 625 mg orally every 8 hours; complete 5–7 days in total according to severity and progress, with earlier narrowing guided by blood and bile cultures. Under the same DBTH acute cholecystitis/cholangitis protocol, if the patient is older than 65 years AND received co-amoxiclav or a cephalosporin in the preceding 2 weeks, use piperacillin/tazobactam 4 g/0.5 g (4.5 g) by intravenous infusion every 8 hours instead, then de-escalate to an appropriate oral antibiotic from cultures or Infection Team advice; the same 5–7-day total course is governed by severity and progress.Do not use in penicillin hypersensitivity or after co-amoxiclav-associated jaundice or hepatic dysfunction. Check renal function: the current 1,000/200 mg intravenous SmPC uses an initial 1,000/200 mg then 500/100 mg every 12 hours for creatinine clearance 10–30 mL/min, or every 24 hours below 10 mL/min; obtain pharmacy or infection advice for the allergy regimen and oral step-down. Review cultures and source control rather than extending broad-spectrum treatment automatically. For piperacillin/tazobactam, the current SmPC specifies infusion over 30 minutes, no renal change above 40 mL/min, 4 g/0.5 g every 8 hours as the maximum at creatinine clearance 20–40 mL/min, and 4 g/0.5 g every 12 hours below 20 mL/min. Avoid it after penicillin hypersensitivity or a severe immediate reaction to another beta-lactam.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Septic shock
Uncontrolled infected obstruction can cause profound vasodilatation, myocardial depression and kidney injury, especially when definitive decompression is delayed.
Hepatic abscess
Persistent or segmental infection may seed focal liver collections that require separate imaging and drainage decisions.
Procedure-related harm
ERCP can cause pancreatitis, bleeding, perforation or recurrent infection if drainage is incomplete or a stent later occludes.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- For a high-risk adult, repeat NEWS2 at least every 30 minutes under NG253 while directly reassessing mental state, perfusion and respiratory signs.
- Track lactate, urine output, creatinine, bilirubin, INR and platelet count through resuscitation and drainage.
- Confirm the endoscopy or radiology referral has been accepted and record the RCHT target: drainage within 24 hours for severe disease and within 48 hours for moderate disease.
- After intervention, inspect for bleeding, pancreatitis, perforation, drain displacement and recurrent fever.
- Assign responsibility for cultures, temporary stents, gallbladder surgery and investigation of any stricture or mass.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Triads are memory aids
Waiting for all three classic features misses patients whose first sign is organ dysfunction.
Drainage can be staged
In an unstable patient, rapid decompression may be safer than prolonged attempts at complete stone clearance.
An occluded stent is a cause
Previous treatment creates new failure modes, so always establish the device type and intended exchange date.
Response proves the plan
A technically successful procedure that does not improve physiology requires review for inadequate drainage, another obstruction or another infection source.
11Common pitfallsFrequent interpretation and management errors.
- 01
Delaying antimicrobials and source-control contact while waiting for MRCP in septic shock.
- 02
Excluding cholangitis because abdominal pain or fever is absent.
- 03
Repeating broad antibiotics when a blocked duct remains undrained.
- 04
Discharging after decompression without a stent or definitive gallstone plan.