Acute Cholangitis and Gallstone Disease
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Direct answer
Acute cholangitis is a bacterial infection of an obstructed biliary tree, most often caused by a stone in the common bile duct. Its classic triad is fever, jaundice and right upper quadrant pain, and the Reynolds pentad adds hypotension and altered mentation to signal severe disease. Antibiotics and resuscitation start at once, and urgent biliary drainage by ERCP is the definitive step, timed by the Tokyo grade.
What you must remember
- Charcot triad: fever, jaundice and right upper quadrant pain; highly specific but seen in only about half of patients or fewer, so its absence does not exclude cholangitis.
- Reynolds pentad: the Charcot triad plus hypotension and confusion or drowsiness, which marks severe disease.
- Tokyo grading: grade I is mild, grade II moderate and grade III severe, based on organ dysfunction and laboratory criteria, and it sets the urgency of drainage.
- Common cause: choledocholithiasis is the commonest cause, and in India Ascaris lumbricoides can migrate into the bile duct and obstruct it.
- Empirical antibiotics: cover Gram-negative enteric organisms, enterococci and anaerobes, then narrow according to cultures and the local antibiogram.
- Biliary colic: episodic pain that settles within hours without fever, unlike acute cholecystitis, where pain persists beyond about six hours with inflammatory signs.
- Gallbladder plan: cholecystectomy is planned after recovery, because the gallbladder remains the source of further stones.
A graded pathway from resuscitation to drainage
A 58-year-old woman with diabetes has one day of fever, rigors, jaundice and right upper quadrant pain. Her blood pressure is 90/60 mmHg and she is drowsy.
- Resuscitate first: Fluids and oxygen are given, blood cultures are drawn before antibiotics, and vasopressors are added if hypotension persists after fluids.
- Start antibiotics early: Empirical Gram-negative and anaerobic cover is given without delay, and the regimen is narrowed when culture reports return.
- Image the duct: Ultrasound shows a dilated common bile duct and often the stone itself, and MRCP is used when the picture remains unclear.
- Drain by the grade: Grade III disease needs urgent ERCP with stone extraction or stenting once resuscitated, while grade II needs early drainage.
- Check the severity markers: Bilirubin, alkaline phosphatase, transaminases and lipase are measured, and a raised lipase suggests coexisting gallstone pancreatitis.
- Plan the gallbladder: Cholecystectomy is timed after the infection settles, since the gallbladder remains the source of further stones.
Where the exam tries to catch you
Cholangitis questions test the triad, the grade and the sequence of care.
- Trap: Doing ERCP first and delaying antibiotics in a septic patient. Correct: Resuscitation and antibiotics start at once, and drainage follows as soon as the grade and the patient's condition allow.
- Trap: Diagnosing biliary colic when fever and jaundice are present. Correct: Fever with jaundice and a dilated duct is cholangitis, which needs antibiotics and drainage rather than a routine colic plan.
- Trap: Calling persistent pain with a positive Murphy sign simple colic. Correct: Pain beyond about six hours with inflammatory signs points to acute cholecystitis, whereas colic resolves within hours.
- Trap: Overlooking Ascaris in an Indian patient with biliary obstruction. Correct: Migrating round worms can block the duct, so endoscopic removal is followed by anthelmintic treatment.
Frequently asked questions
Which investigation is the first-line test for suspected acute cholangitis?
Ultrasound of the abdomen is the usual first-line investigation for suspected acute cholangitis, because it shows a dilated common bile duct and may show the stone. MRCP or ERCP is used when the duct appearance is unclear or the stone cannot be seen.
What does the Tokyo grading of acute cholangitis determine?
The Tokyo grading divides acute cholangitis into grade I mild, grade II moderate and grade III severe, based on organ dysfunction and laboratory values. The grade decides how urgently biliary drainage is needed, so it guides the timing of ERCP.
How does biliary colic differ from acute cholecystitis?
Biliary colic is episodic pain from transient gallstone obstruction, and it settles within hours without fever or a positive Murphy sign. Acute cholecystitis produces pain lasting more than about six hours, with fever, a positive Murphy sign and inflammatory changes on imaging.
Why does ERCP timing matter in acute cholangitis?
ERCP timing in acute cholangitis depends on the Tokyo grade and on the patient's stability after resuscitation. Grade III disease needs urgent drainage once the patient is stabilised, whereas grade I cholangitis often responds to antibiotics alone.