Acute cholangitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 10 Aug 2025

Last updated: 26 Mar 2025

Acute cholangitis is an infection of the biliary tree that requires prompt diagnosis and treatment.

Most patients with acute cholangitis have fever, jaundice, and right upper quadrant pain (Charcot triad).

Cholangitis can quickly become an acute, septic, life-threatening infection that requires rapid evaluation and treatment.

The most common causes are choledocholithiasis and benign or malignant strictures.

Antibiotics alone do not provide sufficient treatment in the majority of patients. Drainage of the biliary tree is the most critical step in management.

If untreated, sepsis with shock, vascular collapse, multiorgan failure, and potentially death can occur.

Definition

Ascending cholangitis is the historical term for the condition currently referred to as acute cholangitis or simply as cholangitis.

Acute cholangitis is an infection of the biliary tree, most commonly caused by obstruction. In its less severe form, there is biliary obstruction with inflammation and bacterial seeding and growth in the biliary tree. It is estimated that 50% to 70% of these patients present with right upper quadrant pain, fever, and jaundice.[1] In the more severe, life-threatening form, known as toxic cholangitis or cholangitis with sepsis, patients have purulent biliary tree contents, as well as evidence of sepsis, hypotension, multiorgan failure, and mental status changes.[1][2]

History and exam

Key diagnostic factors

right upper quadrant (RUQ)/upper abdominal pain
RUQ/upper abdominal tenderness
jaundice
fever

Full details

Other diagnostic factors

pale stools
pruritus
hypotension
mental status changes

Full details

Risk factors

older age
cholelithiasis
benign stricture
malignant stricture
postprocedure injury of bile ducts
history of primary sclerosing cholangitis
history of secondary sclerosing cholangitis
HIV infection
use of immune checkpoint inhibitors
immunoglobulin (Ig) G4-related digestive disease

Full details

Diagnostic tests

1st tests to order

CBC
serum BUN
serum creatinine
blood gas analysis
serum LFTs
CRP
serum potassium
serum magnesium
blood cultures
coagulation panel
transabdominal ultrasound

Full details

Tests to consider

endoscopic retrograde cholangiopancreatography (ERCP)
abdominal CT scan with intravenous contrast
magnetic resonance cholangiopancreatography (MRCP)
endoscopic ultrasonography (EUS)
surgical approaches

Full details

Treatment algorithm

ACUTE

acutely ill

ONGOING

with choledocholithiasis, PSC, or HIV cholangiopathy

Contributors

Expert advisers

Douglas G. Adler, MD, FACG, AGAF, FASGE

Professor of Medicine

Director, Center for Advanced Therapeutic Endoscopy (CATE)

Porter Adventist Hospital, Centura Health

Denver

Disclosures

DGA has provided consulting and speaking services for Abbvie, Boston Scientific Olympus America, and Cook Endoscopy, some of which make products relevant to this topic. He is also an author of references cited in this topic.

Acknowledgements

Dr Douglas G. Adler would like to gratefully acknowledge Dr Andrew S. Fedoravicius, a previous contributor to this topic.

Disclosures

ASF declares that he has no competing interests.

Peer reviewers

Christian Macutkiewicz, MD, FHEA, FRCS

Consultant General & Hepato-Pancreato-Biliary (HPB) Surgeon

Manchester Royal Infirmary

Manchester

Disclosures

CM declares that he has no competing interests.

David J. Hackam, MD, PhD

Associate Professor of Pediatric Surgery

University of Pittsburgh School of Medicine

Pittsburgh

Disclosures

DJH declares that he has no competing interests.

Todd Baron, MD

Professor of Medicine

Division of Gastroenterology & Hepatology

Mayo Clinic Rochester

Rochester

Disclosures

TB is an author of a reference cited in this topic.

Dennis Freshwater, MB, BS, MD, FRCP

Consultant Hepatologist

The Liver and Hepatobiliary Unit

Queen Elizabeth Medical Care Unit

University Hospitals Birmingham NHS Foundation Trust

Birmingham

Disclosures

DF declares that he has no competing interests.

Bertus Eksteen, MRCP, PhD, MRC

Clinical Scientist

University of Birmingham

Honorary Consultant

Liver Transplant Unit

University Hospitals Birmingham NHS Foundation Trust

Birmingham

Disclosures

BE declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ 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.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):17-30.Full text Abstract

Miura F, Okamoto K, Takada T, et al. Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):31-40.Full text Abstract

Gomi H, Solomkin JS, Schlossberg D, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):3-16.Full text Abstract

Mayumi T, Okamoto K, Takada T, et al. Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):96-100.Full text Abstract

Mukai S, Itoi T, Baron TH, et al. Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018. J Hepatobiliary Pancreat Sci. 2017 Oct;24(10):537-49.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Acute cholecystitis
- Peptic ulcer disease
- Acute pancreatitis
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Guidelines
- ACG clinical guideline: diagnosis and management of biliary strictures
- ASGE guideline on the management of cholangitis
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Videos
Venepuncture and phlebotomy: animated demonstration
Peripheral intravascular catheter: animated demonstration
More videos
Patient information
Gallstones
More Patient information
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Acute cholangitis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

acutely ill

with choledocholithiasis, PSC, or HIV cholangiopathy

Contributors

Expert advisers

Douglas G. Adler, MD, FACG, AGAF, FASGE

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Christian Macutkiewicz, MD, FHEA, FRCS

Disclosures

David J. Hackam, MD, PhD

Disclosures

Todd Baron, MD

Disclosures

Dennis Freshwater, MB, BS, MD, FRCP

Disclosures

Bertus Eksteen, MRCP, PhD, MRC

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Videos

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice