Definition: Acute bacterial infection of the bile ducts resulting from common bile duct obstruction. Also called ascending cholangitis. Mortality rate 5-10%

Hepatobiliary Tract Anatomy

Hepatobiliary Tract Anatomy


  • Bile duct develops an obstruction
    • Obstruction may be incomplete (more common) or complete
    • Causes: Gallstones (most common), malignancy, benign stricture, iatrogenic (i.e. ERCP), biliary parasites, primary sclerosing cholangitis (PSC)
  • Elevated intraluminal pressure in the gallbladder leads to translocation of bacteria
    • Bacteria may gain access via lymphatics, portal venous blood or retrograde from the duodenum
    • Common pathogens: E. coli, Klebsiella,  Streptococcus, Enterobacter, Pseudomonas   Other causes: HIV/AIDS cholangiopathy, parasitic infections (Ascaris lumbricoides)


  • Charcot’s Triad: Fever, RUQ pain and jaundice (neither sensitive nor specific)
  • Symptoms
    • Fever/chills
    • Nausea/vomiting
    • Abdominal pain
  • Physical Exam
    • RUQ tenderness to palpation
    • Peritoneal signs are variable
    • Jaundice
    • Frank sepsis (fever, tachycardia, hypotension, tachypnea) is a common presentation
    • Reynold’s Pentad: Charcot’s triad + sepsis and AMS
Acute Cholangitis Infographic (

Acute Cholangitis Infographic (


  • Cholangitis is a clinical diagnosis. There are no diagnostic tests that absolutely clinches or rules out the diagnosis.
  • Laboratory Tests
    • Lab tests are generally neither sensitive nor specific for ruling in or ruling out cholangitis. Below are common findings
    • WBCs – usually elevated but may be depressed in severe infection
    • Hepatic panel
      • Elevated aminotransferases (i.e ALT/AST)
      • Elevated alkaline phosphatase
      • Hyperbilirubinemia
    • Lipase – useful to evaluate for concomitant pancreatitis
    • Blood gas may be useful in patients who appear septic to record lactate level
    • Blood cultures
  • Imaging
    • Imaging is helpful in supporting the diagnosis and aids in identifying the cause. Many patients will have concomitant acute cholecystitis that will be identified on imaging
    • Ultrasound (US)
      Ultrasound with Dilated Common Bile Duct (CBD)

      Ultrasound with Dilated Common Bile Duct (CBD)

      • Common findings
        • Intrahepatic biliary ductal dilation (see video below)
        • Thickening of the bile duct walls
        • Obstructing gallstones
      • Concomitant cholecystitis findings
        • 4 sonographic signs of cholecystitis: Gallstones, gallbladder wall thickening >3mm, pericholecystic fluid, sonographic murphy’s
        • Gallstones + sonographic murphy’s
        • Highly sensitive (87-95%) and specific (82%) when examining the gallbladder and biliary ducts (Carmody 2011, Summers 2010)
      • Not highly sensitive for diagnosing choledocholithiasis: can miss distal CBD stones
      • Useful to distinguish between intrahepatic and extrahepatic obstruction
    • CT Scan
      • Classic finding: non-homogenous liver enhancement during arterial phase
      • Can identify dilated intra- and extrahepatic ducts
      • Gallstones are poorly visualized
      • Findings non-specific
      • Can identify other pathologies or complications of cholangitis (perforation, abscess)
    • Other Diagnostic Imaging
      • Nuclear scintigraphy: may be more sensitive than US in identifying early obstruction
        • Useful when ultrasound results are equivocal and the diagnosis is suspected
        • Cannot visualize the biliary tree with complete obstruction
      • Endoscopic Retrograde Cholangiopancreatography (ERCP)
        • Procedure is both diagnostic + potentially therapeutic
        • Allows removal of obstructing stone, biopsy of mass, culture of bile and decompression or stent placement
      • Magnetic resonance cholangiopancreatography (MRCP)
        • Most sensitive noninvasive method
        • Requires patient to be stable to obtain study

Immediate Management:


  • ABCs, IV, Cardiac Monitor
  • Unstable patients due to sepsis or septic shock should be aggressively resuscitated per general sepsis/septic shock algorithms (IV fluids, airway management as necessary, vasoactive substances etc.)

Directed Management

  • Broad spectrum antibiotics
    • Antibiotics should cover gram positive, anaerobic  gram negative aerobic andenteric organisms (see above)
    • Common regimens
      • Piperacillin/tazobactam (Zosyn®)
      • Imipenem/Meropenem
      • Ampicillin/sulbactam (Unasyn®) + metronidazole
  • Correct electrolyte abnormalities and coagulopathies if present
  • Biliary tract decompression
    • Percutaneous drainage via interventional radiology
    • ERCP via gastroenterology
      • Should be performed emergently if the patient fails to improve with aggressive resuscitation
      • In resuscitation responders, should be performed within 24 hours
    • Surgical drainage


  • All patients with cholangitis will require admission and many will require a high-resource setting (ICU or step down unit)

Take Home Points

  1. Cholangitis is a potentially life-threatening (mortality 5-10%), acute bacterial infection of the bile ducts
  2. Diagnosis is based on clinical findings and while imaging can be supportive, it is frequently non-diagnostic
  3. A normal ultrasound does not rule out acute cholangitis
  4. Treatment focuses on supportive care, broad spectrum antibiotics and consultation with a provider that can provide biliary tract decompression (IR, gastroenterology or general surgery)

Read More

Radiopaedia: Acute cholangitis


Oyama LC: Disorders of the liver and biliary tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 90: p 1186-1205.

Summers S et al. A Prospective Evaluation of Emergency Department Bedside Ultrasonography for the Detection of Acute Cholecystitis. Ann Emerg Med. 2010;56(2): 114-122. PMID: 20138397

Carmody KA, Moore CL, Feller-Kopman D, (eds). Handbook of Critical Care & Emergency Ultrasound. New York, NY: McGraw Hill, 2011, pp.123-144.

Richter J et al. Ultrasound in Tropical and Parasitic Diseases. Lancet 2003; 362:900-902. PMID: 13678978