Cholangitis – Quick Consult
Last Updated / Reviewed: June 2022

Key History
Key Physical Exam
Risk Factors for Cholangitis
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls


Acute cholangitis is a clinical syndrome characterized by fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract; it is typically related to biliary obstruction. The most common cause of biliary obstruction is biliary calculi; it may also be referred to as an ascending cholangitis. The severity of the illness may range from mild to life-threatening.

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Key History

  • Charcot’s Triad: complete triad occurs anywhere from 15% to 70% of patients
    • Fever: 95%
    • Abdominal pain: typically RUQ 90%
    • Jaundice: 80%
  • Reynold's pentad – pain, fever, jaundice, decreased mental status, hypotension
  • History of choledocholithiasis
  • Recent biliary tract manipulation
  • Rigors
  • History of acholic stools
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Key Physical Exam

  • Abdominal Pain
  • Fever
  • Hypotension
  • Scleral icterus
  • Jaundice
  • Mental status changes
  • Mild hepatomegaly
  • Tachycardia
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Risk Factors for Cholangitis

  • Biliary tract manipulation
  • Cholangiocarcinoma
  • Choledochal/biliary cysts
  • Choledocholithiasis – risk factors as gallstones
    • Six F's: female, fair, forty, fat, fertile, flatus
    • fair skinned people of Northern European descent, Hispanics, Native American’s and Pima Indians
  • Hepatolithiasis
  • HIV – cryptosporidium or microsporidia infection
  • Pancreatic cancer
  • Parasitic infection
  • Sickle cell disease
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Differential Diagnosis

  • AIDS related cholangitis
  • Asian cholangitis
  • Cholecystitis
  • Infected choledochal cyst
  • Hepatitis
  • Liver abscess
  • Mirizzi syndrome
  • Pneumonia (RLL)
  • Pyelonephritis
  • Sclerosing cholangitis
  • Septic shock
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Diagnostic Testing

Text / literature information and recommendations include:
  • Labs:
    • CBC: leukocytosis with a left shift is usually present
    • CMP: liver function tests often demonstrate hyperbilirubinemia, elevated alkaline phosphatase, and elevated transaminases
    • Blood cultures are positive in up to 50% of cases
  • Imaging:
    • Ultrasound (US) is a quick way to access for bile duct dilatation. 96% accuracy for ductal dilatation; may be performed at bedside and may image other structures. It is operator dependent and there is a decreased sensitivity for common bile duct stones. Early in the course the common bile duct may not have dilated and gallstones may be too small to visualize via US. A normal sonogram does not rule out acute cholangitis.
    • CT scan cholangiography is useful for imaging the biliary tree and to identify other pathologies. Gallstones are poorly visualized and there is a diminished ability to visualize the biliary tree if the serum bilirubin is elevated
    • Magnetic resonance cholangiopancreatography (MRCP) is accurate for retained stones in the biliary system. Limitations of MRCP include the inability for invasive diagnostic test.
    • Plain films are limited in their diagnostic value. May visualize air in the biliary tree, air in gallbladder wall indicating emphysematous cholecystitis may be seen.
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Clinical Risk and Safety Pearls

  • Maintain a high clinical suspicion as delay in diagnosis may result in a higher death rate.
  • Patients on corticosteroids and elderly patients may present only with hypotension.
  • Suspect cholangitis in older patients who present with sepsis, hypotension or confusion.
  • Suspect cholangitis in any patient with jaundice and a fever.
  • Clinical findings in cholangitis can range from mild illness to fulminant sepsis.
  • It is often difficult to differentiate cholecystitis from cholangitis. Jaundice and an elevated bilirubin are more common in cholangitis.
  • Suspect cholangitis in pregnant women who present with jaundice or fever. Pregnant women are prone to symptomatic gallstones.
  • Cholelithiasis and cholangitis are uncommon in children unless they have an underlying biliary tree abnormality or hemolytic disorder.
  • Oriental cholangiohepatitis is endemic in Southeast Asia.
  • See characteristics associated with poorer outcome under Complications (below).
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Common text / literature recommendations include:
  • ABCs
  • IV fluid resuscitation
  • Correction of electrolytes, coagulopathy if present
  • Blood cultures
  • Parenteral broad-spectrum antibiotics with coverage for gram-negative bacteria and enterococcus. Anaerobic coverage can be added in sick patients or patients who have had biliary tract instrumentation
  • Establishment of urgent biliary drainage for patients with:
    • Persistent abdominal pain after conservative treatment
    • Hypotension after fluid resuscitation
    • Fever over 39° C
    • Mental confusion
  • Biliary drainage can be accomplished by ERCP, direct percutaneous approach or by surgical decompression.
  • Endoscopic sphincterotomy with stone extraction and stent insertion is the current treatment of choice for establishing biliary drainage in acute cholangitis.
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  • Acute renal failure
  • Liver failure
  • Pyogenic liver abscess
  • Bacteremia
Characteristics associated with poor outcome:
  • Hypotension
  • Acute renal failure
  • Cirrhosis
  • Inflammatory bowel disease
  • High malignant strictures
  • Radiologic cholangitis – post percutaneous transhepatic cholangiography
  • Age older than 50 years
  • Failure to respond to antibiotics and conservative therapy
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  1. Ahmed M. Acute cholangitis – an update. World J Gastrointest Pathophysiol. 2018;9(1):1-7.
  2. Mosler P. Diagnosis and management of acute cholangitis. Curr Gastroenterol Rep. 2011; 13:166.
  3. Yeom DH, Oh HJ, Son YW, Kim TH. What are the risk factors for acute suppurative cholangitis caused by common bile duct stones? Gut Liver. 2010; 4:363.
  4. Wah L, Christophi C, Muralidharan V. Acute cholangitis: Current concepts. ANZ J Surg. 2017;87(7-8):554-559.

This is intended solely as reference material and is not a recommendation for any specific patient. The practitioner must rely upon his or her own professional judgment and medical decision-making to determine whether it is relevant in a particular case. Materials are derived from medical and nursing texts, medical literature and national guidelines and should not be considered complete or authoritative. Users must rely on specific patient presentation, experience and judgment when utilizing any of the information contained herein relative to an actual patient.

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