Acute cholangitis

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

Last reviewed: 17 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]

História e exame físico

Principais fatores diagnósticos

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

Detalhes completos

Outros fatores diagnósticos

pale stools
pruritus
hypotension
mental status changes

Detalhes completos

Fatores de risco

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

Detalhes completos

Investigações diagnósticas

Primeiras investigações a serem solicitadas

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

Detalhes completos

Investigações a serem consideradas

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

Detalhes completos

Algoritmo de tratamento

AGUDA

acutely ill

CONTÍNUA

with choledocholithiasis, PSC, or HIV cholangiopathy

Colaboradores

Consultores especialistas

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

Professor of Medicine

Director, Center for Advanced Therapeutic Endoscopy (CATE)

Porter Adventist Hospital, Centura Health

Denver

Declarações

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.

Agradecimentos

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

Declarações

ASF declares that he has no competing interests.

Revisores

Christian Macutkiewicz, MD, FHEA, FRCS

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

Manchester Royal Infirmary

Manchester

Declarações

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

Declarações

DJH declares that he has no competing interests.

Todd Baron, MD

Professor of Medicine

Division of Gastroenterology & Hepatology

Mayo Clinic Rochester

Rochester

Declarações

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

Declarações

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

Declarações

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.

Referências

Nossas equipes internas de editoria e de evidências trabalham em conjunto com colaboradores internacionais especializados e pares revisores para garantir que forneçamos acesso às informações o mais clinicamente relevantes possível.

Principais artigos

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.Texto completo Resumo

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.Texto completo Resumo

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.Texto completo Resumo

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.Texto completo Resumo

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.Texto completo Resumo

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

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- Acute cholecystitis
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Рекомендации
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Acute cholangitis

Summary

Definition

História e exame físico

Principais fatores diagnósticos

Outros fatores diagnósticos

Fatores de risco

Investigações diagnósticas

Primeiras investigações a serem solicitadas

Investigações a serem consideradas

Algoritmo de tratamento

acutely ill

with choledocholithiasis, PSC, or HIV cholangiopathy

Colaboradores

Consultores especialistas

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

Declarações

Agradecimentos

Declarações

Revisores

Christian Macutkiewicz, MD, FHEA, FRCS

Declarações

David J. Hackam, MD, PhD

Declarações

Todd Baron, MD

Declarações

Dennis Freshwater, MB, BS, MD, FRCP

Declarações

Bertus Eksteen, MRCP, PhD, MRC

Declarações

Peer reviewer acknowledgements

Disclosures

Referências

Principais artigos

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Отличия

Рекомендации

Videos

Лифлеты для пациента

Войдите в учетную запись или оформите подписку, чтобы получить полноценный доступ к BMJ Best Practice

Войдите в учетную запись или оформите подписку, чтобы получить полноценный доступ к BMJ Best Practice

Войдите в учетную запись, чтобы получить полноценный доступ к BMJ Best Practice