{
  "schemaVersion": 2,
  "eyebrow": "Hepatobiliary emergency",
  "title": "Cholangitis",
  "summary": "Acute cholangitis is biliary infection with potential for rapid sepsis and organ failure. Management hinges on immediate resuscitation and antibiotics, severity assessment, and timely biliary drainage when obstruction persists or disease is severe.",
  "seoDescription": "Physician-focused review of acute cholangitis diagnosis, initial stabilization, antimicrobial therapy, severity assessment, and indications for urgent biliary drainage.",
  "clinicalQuestion": "How should physicians recognize, stabilize, and obtain source control for suspected acute cholangitis?",
  "specialty": "Gastroenterology and Hepatology",
  "audience": "U.S. physicians and medical trainees",
  "tags": [
    "acute cholangitis",
    "biliary sepsis",
    "biliary obstruction",
    "ERCP",
    "biliary drainage"
  ],
  "keyTakeaways": [
    "Treat suspected acute cholangitis as a time-sensitive biliary sepsis syndrome: begin resuscitation and empiric antibiotics while arranging evaluation for obstruction and drainage. [9][20]",
    "Hypotension, multiorgan failure, or altered mental status identify a life-threatening presentation requiring urgent source-control planning. [9][20]",
    "Endoscopic biliary drainage is an effective initial intervention for severe cholangitis due to choledocholithiasis. [18]",
    "In PSC, cholangitis may occur without a major change from baseline liver biochemistries; prior ERCP and indwelling stents increase infectious risk. [12]"
  ],
  "sections": [
    {
      "id": "clinical-recognition",
      "eyebrow": "Recognition",
      "heading": "Identify acute cholangitis as biliary infection with systemic risk",
      "intro": "Do not require classic symptom complexes before initiating a sepsis-oriented evaluation.",
      "paragraphs": [
        "Acute cholangitis is a life-threatening infection of the biliary tract. Clinical recognition should integrate jaundice, fever or chills, and right-upper-quadrant pain with laboratory evidence and imaging findings suggestive of biliary obstruction or infection. [20][24]",
        "Charcot triad and Reynolds pentad are historically important but have limited diagnostic sensitivity; their absence should not defer treatment in a patient with suspected biliary sepsis. [20] Toxic or severe cholangitis is characterized by purulent biliary contents with sepsis, hypotension, multiorgan failure, or mental-status change. [9]"
      ],
      "bullets": [
        "Escalate immediately for hypotension, altered mental status, organ dysfunction, or other features of sepsis; these findings indicate a high-risk presentation in which delayed biliary decompression may be harmful. [9][20]",
        "In patients with PSC, evaluate compatible fever, rigors, abdominal pain, jaundice, or clinical deterioration even if liver tests are not substantially different from baseline. [12]"
      ],
      "subsections": [],
      "table": {
        "caption": "Clinical findings that should change urgency in suspected cholangitis. [9][20][24]",
        "columns": [
          "Finding",
          "Clinical implication"
        ],
        "rows": [
          [
            "Jaundice, fever or chills, right-upper-quadrant pain with supportive laboratory and imaging findings",
            "Supports acute cholangitis; begin sepsis-directed management while defining obstruction and drainage needs. [20][24]"
          ],
          [
            "Hypotension, multiorgan failure, altered mental status",
            "Life-threatening or toxic cholangitis phenotype; urgent source-control planning is required. [9][20]"
          ],
          [
            "PSC with compatible infectious symptoms but little biochemical change",
            "Do not exclude cholangitis on the basis of stable baseline liver tests alone. [12]"
          ]
        ]
      }
    },
    {
      "id": "initial-management",
      "eyebrow": "First hours",
      "heading": "Stabilize and start empiric antimicrobial therapy before source control",
      "intro": "Management should proceed in parallel rather than sequentially.",
      "paragraphs": [
        "Early recognition, fluid resuscitation, broad-spectrum antibiotics, and biliary intervention have improved outcomes in acute cholangitis. [20] Obtain diagnostic studies and cultures when feasible without delaying antimicrobials or urgent drainage in unstable patients; the supplied sources do not provide a validated U.S. empiric regimen, dose, or treatment duration.",
        "Antibiotic selection should therefore follow local biliary-infection pathways, prior culture data, recent antimicrobial exposure, health care exposure, renal function, allergy history, and the anticipated drainage procedure. This article does not specify drug doses because the supplied evidence does not support regimen-level recommendations."
      ],
      "bullets": [
        "Resuscitate as for sepsis, with frequent reassessment of hemodynamics, mental status, oxygenation, urine output, and evolving organ dysfunction. [9][20]",
        "Obtain early gastroenterology/endoscopy and, when appropriate, interventional radiology or surgical consultation for anticipated biliary decompression. [18][20]",
        "Do not use improvement in laboratory values alone as a substitute for reassessment of ongoing obstruction or need for source control. This operational point is based on the central role of drainage in severe disease. [18][20]"
      ],
      "subsections": [],
      "table": {
        "caption": "Parallel actions in suspected acute cholangitis. [9][18][20]",
        "columns": [
          "Priority",
          "Action",
          "Decision consequence"
        ],
        "rows": [
          [
            "Stabilization",
            "Initiate sepsis-directed resuscitation and monitor for hypotension, organ failure, and altered mental status. [9][20]",
            "Identifies patients requiring urgent escalation and source control. [9][20]"
          ],
          [
            "Infection treatment",
            "Administer early empiric broad-spectrum antibiotics. [20]",
            "Do not defer antimicrobial therapy while arranging definitive drainage. [20]"
          ],
          [
            "Source control",
            "Assess for biliary obstruction and arrange biliary drainage, particularly in severe disease. [18][20]",
            "Persistent obstruction or severe illness should lower the threshold for urgent intervention. [18][20]"
          ]
        ]
      }
    },
    {
      "id": "biliary-drainage",
      "eyebrow": "Source control",
      "heading": "Use biliary drainage to control obstruction-associated severe cholangitis",
      "intro": "Drainage addresses the obstructed infected biliary system when medical therapy alone is insufficient.",
      "paragraphs": [
        "For severe acute cholangitis caused by choledocholithiasis, endoscopic biliary drainage has been shown to be a safe and effective initial measure for control of the acute episode. [18] ERCP-based therapy is therefore central when endoscopic access is feasible and prompt decompression is needed.",
        "Stone-directed definitive management may follow stabilization. In a reported management approach for gallstone cholangitis, ERCP with endoscopic sphincterotomy was followed by interval laparoscopic cholecystectomy. [17] The supplied sources do not establish a universal timing target for ERCP, specify a preferred endoscopic technique for every obstruction, or support recommendations on post-drainage antibiotic duration."
      ],
      "bullets": [
        "Prioritize urgent drainage in severe disease, especially with sepsis physiology or organ dysfunction. [9][18][20]",
        "Use multidisciplinary planning when ERCP is unavailable, unsuccessful, or anatomically impractical; the supplied sources do not provide comparative evidence to rank alternative drainage methods.",
        "After biliary instrumentation, monitor for recurrent infection and procedure-related complications; in PSC, risk is particularly relevant when stents remain in place. [12]"
      ],
      "subsections": [],
      "table": {
        "caption": "Drainage-related decisions supported by the available evidence. [12][17][18]",
        "columns": [
          "Scenario",
          "Management implication"
        ],
        "rows": [
          [
            "Severe cholangitis from choledocholithiasis",
            "Endoscopic biliary drainage is an effective initial control strategy. [18]"
          ],
          [
            "Gallstone cholangitis after endoscopic treatment",
            "ERCP with sphincterotomy followed by interval laparoscopic cholecystectomy has been reported as a management approach. [17]"
          ],
          [
            "PSC after ERCP or with an indwelling stent",
            "Maintain a high index of suspicion for cholangitis; prior instrumentation and retained stents are associated with higher bacterobilia and infection risk. [12]"
          ]
        ]
      }
    },
    {
      "id": "special-contexts",
      "eyebrow": "Chronic cholangiopathy",
      "heading": "Recognize cholangitis in primary sclerosing cholangitis",
      "intro": "PSC changes the interpretation of laboratory tests and procedural risk.",
      "paragraphs": [
        "Cholangitis is a common complication of PSC. Infection may be segmental and can occur without a significant change in baseline liver biochemistry, so clinical assessment and evaluation for a relevant stricture or other biliary complication are important. [12]",
        "Previous ERCP, therapeutic intervention, and especially retained biliary stents are risk factors for bacterobilia and cholangitis in PSC. [12] A patient with PSC and suspected cholangitis should be managed with early specialist involvement because the differential includes clinically significant stricture and cholangiocarcinoma."
      ],
      "bullets": [
        "Refer clinically suspected cholangiocarcinoma in PSC for specialist multidisciplinary review. [12]",
        "For adult PSC, AGA expert review advises considering surveillance for cholangiocarcinoma and gallbladder cancer using ultrasound, CT, or MRI, with or without CA 19-9, every 6 to 12 months. [23]",
        "Gallbladder polyps larger than 8 mm in PSC carry increased gallbladder-cancer risk in the AGA review; operative decisions should also consider growth and clinical status. [23]"
      ],
      "subsections": [],
      "table": null
    },
    {
      "id": "disposition-and-follow-up",
      "eyebrow": "After stabilization",
      "heading": "Reassess response and address the cause of obstruction",
      "intro": "Disposition depends on physiologic trajectory and adequacy of source control.",
      "paragraphs": [
        "Continue close reassessment after antibiotics and drainage for hemodynamic improvement, resolution of organ dysfunction, and evidence that biliary source control is adequate. Severe cholangitis requires a level of monitoring capable of managing sepsis and rapidly escalating organ support. [9][20]",
        "For gallstone-associated disease, transition from acute decompression to a definitive plan for stone disease and cholecystectomy when clinically appropriate. [17] In PSC or when a malignancy-associated obstruction is suspected, coordinate follow-up with hepatology, therapeutic endoscopy, surgery, oncology, and multidisciplinary review as indicated. [12][23]"
      ],
      "bullets": [
        "Re-evaluate recurrent fever, sepsis, or failure to improve for unresolved obstruction, inadequate drainage, a stent-related complication, or an alternative diagnosis. This is consistent with the need for source control in severe disease and the instrumentation-associated risk observed in PSC. [12][18][20]",
        "Do not infer a specific antibiotic stop date from this review; duration after successful drainage is not provided in the supplied sources."
      ],
      "subsections": [],
      "table": null
    }
  ],
  "faq": [
    {
      "question": "Does absence of Charcot triad exclude acute cholangitis?",
      "answer": "No. Classic symptom complexes have poor sensitivity. Diagnose using the overall clinical syndrome, laboratory findings, and imaging evidence of biliary disease, and do not delay treatment in a patient with suspected biliary sepsis. [20][24]"
    },
    {
      "question": "When is biliary drainage most urgent?",
      "answer": "Urgency is highest with severe disease, particularly hypotension, altered mental status, multiorgan failure, or other sepsis physiology. Endoscopic biliary drainage is an effective initial intervention for severe cholangitis due to choledocholithiasis. [9][18][20]"
    },
    {
      "question": "Can PSC-associated cholangitis occur with stable liver tests?",
      "answer": "Yes. PSC-related infection may be limited to small hepatic segments and may not produce a significant change in baseline liver biochemistry. Prior ERCP and retained stents further increase infectious risk. [12]"
    },
    {
      "question": "What surveillance is considered for hepatobiliary cancer in PSC?",
      "answer": "AGA expert review advises considering ultrasound, CT, or MRI, with or without CA 19-9, every 6 to 12 months for cholangiocarcinoma and gallbladder-cancer surveillance in adult PSC. [23]"
    }
  ],
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  "editorialNote": "Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.",
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      "snippet": "(8.0) Source: Study A3921096 CSR, table 14.3.4.1.8 (page 3627) 5.3.2.3 Is an alternative dosing regimen or management strategy required for subpopulations based on intrinsic patient factors? Renal/Hepatic impairment The Applicant proposed the following dosing instructions for patients with renal or ",
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      "snippet": "twice daily (2.2) • See full prescribing information for dosage modifications due to renal impairment and hepatic impairment. (2.6, 2.7) ---------------------DOSAGE FORMS AND STRENGTHS---------------------- Capsules: 200 mg (3) -------------------------------CONTRAINDICATIONS------------------------",
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      "snippet": "# Guideline Update: Primary Sclerosing Cholangitis\n\nAlthough primary sclerosing cholangitis (PSC) is an uncommon cause of chronic liver disease, it is one of the major causes of cholestatic liver disease. Based on data obtained from new imaging modalities and recent treatment trials, guidelines for ",
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      "snippet": "###### Disclosures\n\nPeer reviewer affiliations and disclosures pertain to the time of the review.\n\n### References\n\n#### Key articles\n\nKiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sc",
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      "snippet": "##### Peer reviewer acknowledgements\n\nBMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.\n\n###### Disclosures\n\nPeer reviewer affiliations an",
      "score": 0.46701634
    },
    {
      "number": 11,
      "title": "Primary biliary cholangitis - Symptoms, diagnosis and ...",
      "detail": "bestpractice.bmj.com",
      "url": "https://bestpractice.bmj.com/topics/en-us/344",
      "authors": "bestpractice.bmj.com",
      "host": "bestpractice.bmj.com",
      "snippet": "### References\n\n#### Key articles\n\nHirschfield GM, Dyson JK, Alexander GJM, et al. The British Society of Gastroenterology/UK-PBC primary biliary cholangitis treatment and management guidelines. Gut. 2018 Sep;67(9):1568-94.Full textAbstract\n\nLindor KD, Bowlus CL, Boyer J, et al. Primary biliary chol",
      "score": 0.4558047
    },
    {
      "number": 12,
      "title": "British Society of Gastroenterology and UK-PSC guidelines ...",
      "detail": "gut.bmj.com",
      "url": "https://gut.bmj.com/content/68/8/1356",
      "authors": "gut.bmj.com",
      "host": "gut.bmj.com",
      "snippet": "These guidelines on the management of primary sclerosing cholangitis (PSC) were commissioned by the British Society of Gastroenterology liver section. The guideline writing committee included medical representatives from hepatology and gastroenterology groups as well as patient representatives from ",
      "score": 0.3183691
    },
    {
      "number": 13,
      "title": "Prognostic factors for transplant-free survival in patients ...",
      "detail": "bmjopengastro.bmj.com",
      "url": "https://bmjopengastro.bmj.com/content/12/1/e001571",
      "authors": "bmjopengastro.bmj.com",
      "host": "bmjopengastro.bmj.com",
      "snippet": "by G Konstantis · 2025 · Cited by 1 — Objective Secondary sclerosing cholangitis (SSC) represents a disease with a poor prognosis increasingly diagnosed in clinical settings.",
      "score": 0.3485348
    },
    {
      "number": 14,
      "title": "The British Society of Gastroenterology/UK-PBC primary ...",
      "detail": "gut.bmj.com",
      "url": "https://gut.bmj.com/content/67/9/1568",
      "authors": "gut.bmj.com",
      "host": "gut.bmj.com",
      "snippet": "The BSG/UK-PBC consensus care pathway for patients with primary biliary cholangitis (PBC). While care needs always to be personalised to the patient, there are consensus pathways that are important for patients with PBC, which encompass the important ‘pillars’ of care that are believed to provide op",
      "score": 0.25632483
    },
    {
      "number": 15,
      "title": "Treatment of cholangiocarcinoma in patients with primary ...",
      "detail": "egastroenterology.bmj.com",
      "url": "https://egastroenterology.bmj.com/content/2/1/e100045",
      "authors": "egastroenterology.bmj.com",
      "host": "egastroenterology.bmj.com",
      "snippet": "by C Villard · 2024 · Cited by 16 — cholangitis (PSC) a 5-year overall survival (OS) and disease-free survival (DFS) of approximately 20%.73 … a 64% 5-year survival in the",
      "score": 0.23641086
    },
    {
      "number": 16,
      "title": "Acute cholecystitis - Symptoms, diagnosis and treatment",
      "detail": "bestpractice.bmj.com",
      "url": "https://bestpractice.bmj.com/topics/en-us/78",
      "authors": "bestpractice.bmj.com",
      "host": "bestpractice.bmj.com",
      "snippet": "### References\n\n#### Key articles\n\nYokoe M, Hata J, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):41-54.Full textAbstract\n\nPisano M, Allievi N, Gurusamy K, et al. 2020 World Society ",
      "score": 0.1778826
    },
    {
      "number": 17,
      "title": "Management of Gallstone Cholangitis in the Era ...",
      "detail": "jamanetwork.com",
      "url": "https://jamanetwork.com/journals/jamasurgery/fullarticle/390880",
      "authors": "jamanetwork.com",
      "host": "jamanetwork.com",
      "snippet": "by RTP Poon · 2001 · Cited by 100 — The main treatments were endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) followed by interval LC.",
      "score": 0.45188335
    },
    {
      "number": 18,
      "title": "Endoscopic Biliary Drainage for Severe Acute Cholangitis",
      "detail": "www.nejm.org",
      "url": "https://www.nejm.org/doi/full/10.1056/NEJM199206113262401",
      "authors": "www.nejm.org",
      "host": "www.nejm.org",
      "snippet": "by ECS Lai · 1992 · Cited by 815 — Endoscopic biliary drainage is a safe and effective measure for the initial control of severe acute cholangitis due to choledocholithiasis and",
      "score": 0.15422338
    },
    {
      "number": 19,
      "title": "ACG Clinical Guideline: Primary Sclerosing Cholangitis",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/ajg2015112.pdf?origin=ppub",
      "authors": "www.nature.com",
      "host": "www.nature.com",
      "snippet": "by KD Lindor · 2015 · Cited by 700 — Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver and biliary tract disease that has a highly variable natural history. ( 1 ).",
      "score": 0.5164741
    },
    {
      "number": 20,
      "title": "The Emergency Medicine−Focused Review of Cholangitis",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S0736467917306157",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "Untreated, mortality from acute cholangitis approaches 100%, making identification and appropriate management by emergency physicians imperative (1). Since cholangitis was first described in 1877, diagnostic and treatment modalities have improved significantly (1). However, diagnosis of cholangitis ",
      "score": 0.5726516
    },
    {
      "number": 21,
      "title": "Official journal of the American College of Gastroenterology | ACG",
      "detail": "journals.lww.com",
      "url": "https://journals.lww.com/ajg/fulltext/2017/09000/strategies_to_combat_physician_burnout_in.2.aspx",
      "authors": "journals.lww.com",
      "host": "journals.lww.com",
      "snippet": "### Secondary Logo. ### Journal Logo. Colleague's E-mail is Invalid. Your message has been successfully sent to your colleague. # Strategies to Combat Physician Burnout in Gastroenterology. Anderson, Joseph C MD1; Pfeil, Sheryl MD2; Surawicz, Christina MD3. 1Section of Gastroenterology, Geisel Schoo",
      "score": 0.5457947
    },
    {
      "number": 22,
      "title": "Incidence, clinical spectrum, and outcomes of primary sclerosing cholangitis in a united states community - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/pii/S0016508503013568",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "# Clinical-liver pancreas and biliary tract Incidence, clinical spectrum, and outcomes of primary sclerosing cholangitis in a united states community. The epidemiology of primary sclerosing cholangitis (PSC) in the United States is unknown. Using the Rochester Epidemiology Project, a medical records",
      "score": 0.49729064
    },
    {
      "number": 23,
      "title": "AGA Clinical Practice Update on Surveillance for Hepatobiliary Cancers in Patients With Primary Sclerosing Cholangitis: Expert Review - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S154235651930744X",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "Title: AGA Clinical Practice Update on Surveillance for Hepatobiliary Cancers in Patients With Primary Sclerosing Cholangitis: Expert Review - ScienceDirect\n## Article preview. ## Clinical Gastroenterology and Hepatology. # Clinical practice update AGA Clinical Practice Update on Surveillance for He",
      "score": 0.43669468
    },
    {
      "number": 24,
      "title": "Diagnostic Imaging of Suspected Acute Cholecystitis and ...",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/cid/article/79/Supplement_3/S104/7706134",
      "authors": "academic.oup.com",
      "host": "academic.oup.com",
      "snippet": "by RA Bonomo · 2024 · Cited by 121 — The diagnosis of acute cholangitis should include clinical signs (jaundice, fever, chills, and RUQ abdominal pain), laboratory findings (indicators of",
      "score": 0.41962478
    }
  ],
  "publishedAt": "2026-08-21T00:36:48.322699+00:00",
  "updatedAt": "2026-08-21T00:36:48.322699+00:00",
  "readingMinutes": 4,
  "slug": "cholangitis"
}