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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Obstruction with infection
A common-duct stone accompanied by fever, worsening pain, hypotension or altered consciousness may have caused ascending cholangitis and septic shock.
Action: Resuscitate, take cultures when immediately feasible, start the local intravenous biliary-sepsis regimen and obtain urgent specialist biliary drainage rather than awaiting elective stone work-up.
Synopsis
Recognise common-bile-duct stones, distinguish obstruction from infected cholangitis and malignant jaundice, and choose non-invasive imaging or therapeutic duct clearance according to probability and urgency.
Consider choledocholithiasis when jaundice or cholestatic liver tests accompany gallstone symptoms, pancreatitis or a dilated common bile duct.
Begin with liver tests and ultrasound, noting that ultrasound may show duct dilatation without visualising the causative stone.
Use MRCP when ultrasound is negative for duct stones but the common duct is dilated or liver tests are abnormal.
Key red flags
Jaundice with fever, rigors, hypotension or confusion is a source-control emergency.
Painless progressive jaundice, weight loss or a palpable gallbladder should prompt evaluation for malignant obstruction rather than an assumption of stones.
Infected obstruction
Rigors, fever, haemodynamic change or confusion convert a duct-stone work-up into urgent cholangitis management.
Worked case: probable duct stoneSelect the next test
An adult with episodic biliary pain has bilirubin 58 micromol/L and a 9 mm common bile duct on ultrasound, but no duct stone is seen and there is no fever or organ dysfunction.
Recognise a substantial probability of choledocholithiasis while confirming that acute cholangitis is not currently present.
Request MRCP to define duct anatomy because ultrasound is negative for a stone but liver tests and duct calibre remain abnormal.
Key medicines
Co-amoxiclav only when duct obstruction is infected: current DBTH adult exampleIf an adult with choledocholithiasis has acute cholangitis and is 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, after effective drainage with clinical improvement and reliable absorption, switch to 625 mg orally every 8 hours; total treatment is 5–7 days according to severity, progress and 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.Avoid in penicillin hypersensitivity or previous 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; seek pharmacy advice for oral dosing and the local allergy alternative. Review blood and bile cultures and do not let antimicrobials delay decompression. 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.