Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 7 Sept 2026Clinical review pending
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Infected obstruction is a source-control emergency
Cholangitis combines bacterial infection with impaired bile drainage; shock, altered consciousness, rising lactate or organ dysfunction indicates severe disease and predicts failure of antibiotics alone.
Action: Call senior surgical, gastroenterology, anaesthetic and critical-care teams, begin sepsis treatment, obtain blood cultures when rapidly possible, and secure urgent biliary decompression through the fastest competent route.
Synopsis
Identify infected biliary obstruction before classical signs are complete, resuscitate sepsis, and coordinate antibiotics with urgent endoscopic, radiological or operative drainage.
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.
Key red flags
Hypotension, confusion, oliguria, hypoxaemia or rising lactate with cholestasis indicates severe cholangitis even without the full Charcot triad.
Failure to improve after antibiotics suggests persistent obstruction, resistant infection or another source and demands renewed drainage assessment.
Septic physiology
Hypotension, altered mental state, tachypnoea and oliguria identify immediate risk and take priority over perfect anatomical classification.
Investigation priorities
01
Blood culturesFirst step
Identify bacteraemia and guide narrowed treatment.
Management branches
Worked case: septic obstructive jaundiceDrain while resuscitating
A 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.
Recognise severe ascending cholangitis with organ dysfunction and call emergency senior, endoscopy, anaesthetic and critical-care support.
Obtain 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.
Key medicines
Co-amoxiclav for acute cholangitis: current DBTH adult exampleFor 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.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 7 Sept 2026; clinical approval remains outstanding.