Acute cholangitis

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

Last reviewed: 1 Jun 2025

Last updated: 18 Jul 2023

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's triad).

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

The most common causes are choledocholithiasis and benign and 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, multi-organ failure, and potentially death can occur.

Definition

Acute cholangitis, previously known as ascending 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, multi-organ failure, and mental status changes.[1][2]

History and exam

Key diagnostic factors

presence of risk 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

age >50 years
cholelithiasis
benign stricture
malignant stricture
post-procedure injury of bile ducts
history of primary sclerosing cholangitis
history of secondary sclerosing cholangitis
HIV infection
immune checkpoint inhibitors
IgG4-related disease

Full details

Diagnostic investigations

1st investigations to order

FBC
serum urea
serum creatinine
ABG analysis
serum LFTs
CRP
serum potassium
serum magnesium
blood cultures
coagulation panel
transabdominal ultrasound

Full details

Investigations to consider

abdominal CT scan with intravenous contrast
endoscopic retrograde cholangiopancreatography (ERCP)
magnetic resonance cholangiopancreatography (MRCP)
percutaneous trans-hepatic cholangiography (PTC)
endoscopic ultrasonography (EUS)

Full details

Treatment algorithm

ACUTE

acutely ill

ONGOING

with choledocholithiasis, PSC, or HIV cholangiopathy

Contributors

Expert advisers

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.

Acknowledgements

BMJ Best Practice would like to gratefully acknowledge the previous expert contributor, whose work has been retained in parts of the content:

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 consulted for Boston Scientific, Merit Medical, and Olympus, who make endoscopic retrograde cholangio-pancreatography (ERCP) products, and has also consulted for AbbVie Pharmaceuticals. He is an author of references cited in this topic.

Peer reviewers

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 declares that he has no competing interests.

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.

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

National Institute for Health and Care Excellence. Gallstone disease: diagnosis and management. October 2014 [internet publication].Full text

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

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
More Differentials
Guidelines
- ACG clinical guideline: diagnosis and management of biliary strictures
- ASGE guideline on the management of cholangitis
More Guidelines
Videos
Venepuncture and phlebotomy animated demonstration
Peripheral venous cannulation 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 investigations

1st investigations to order

Investigations to consider

Treatment algorithm

acutely ill

with choledocholithiasis, PSC, or HIV cholangiopathy

Contributors

Expert advisers

Christian Macutkiewicz, MD, FHEA, FRCS

Disclosures

Acknowledgements

Peer reviewers

David J. Hackam, MD, PhD

Disclosures

Todd Baron, MD

Disclosures

Dennis Freshwater, MB, BS, MD, FRCP

Disclosures

Bertus Eksteen, MRCP, PhD, MRC

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