Cholangitis (Acute/Ascending Cholangitis)

Acute cholangitis — also called ascending cholangitis — is an infection of the biliary tract that results from the combination of bile duct obstruction and bacterial growth in stagnant bile (Sornsenee et al., PLoS One, 2025). It is a serious condition: even with modern treatment, severe cases carry a mortality rate as high as 30% (Sornsenee et al., PLoS One, 2025).

Choledocholithiasis — a gallstone lodged in the common bile duct — is the cause of acute cholangitis in up to 70% of cases, which places this condition squarely within the spectrum of gallstone disease (Neitzel et al., Journal of Intensive Care Medicine, 2025). Other causes include benign or malignant biliary strictures (10–30% of cases) and infection introduced by previous endoscopic, percutaneous, or surgical instrumentation of the bile ducts (Neitzel et al., Journal of Intensive Care Medicine, 2025). The infection is most often caused by gram-negative bacteria that ascend from the intestine — chiefly Escherichia coli, Klebsiella pneumoniae, and Enterobacter species — found in 60–90% of cases (Sornsenee et al., PLoS One, 2025).

The modern framework for diagnosis and severity grading is the Tokyo Guidelines (TG18), which classify cholangitis as mild (Grade I), moderate (Grade II), or severe (Grade III) and direct the urgency of biliary drainage (Martínez Márquez et al., Abdominal Radiology, 2026). Because the two pillars of treatment — antibiotics and biliary decompression — are time-sensitive, prompt recognition is essential (Perri & Raiford, Yamada's Textbook of Gastroenterology, 2022).

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Acute cholangitis requires both an obstruction and bacterial contamination of bile (Coccolini et al., WSES Guidelines, 2023):

• Choledocholithiasis (most common) — a gallstone that has migrated from the gallbladder into the common bile duct, responsible for up to 70% of cases (Neitzel et al., Journal of Intensive Care Medicine, 2025).

• Biliary strictures — benign (post-operative, chronic pancreatitis, primary/secondary sclerosing cholangitis, autoimmune) or malignant (cholangiocarcinoma, pancreatic adenocarcinoma, ampullary carcinoma, metastases), accounting for 10–30% of cases (Neitzel et al., Journal of Intensive Care Medicine, 2025).

• Biliary instrumentation — infection introduced by prior ERCP, percutaneous procedures, or biliary surgery; indwelling biliary stents are a particular risk (Parikh et al., Surgical Endoscopy, 2021).

• Bacterial ascent and stasis — obstruction causes bile to stagnate, allowing gram-negative enteric bacteria to proliferate and invade the biliary tree (Sornsenee et al., PLoS One, 2025).

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Because gallstones are the dominant cause, the risk factors overlap with gallstone disease, with additional biliary-specific contributors (Markotic et al., Cochrane Database, 2020; Parikh et al., Surgical Endoscopy, 2021):

• Pre-existing gallstones and choledocholithiasis

• Older age — most patients are in their late 60s to 70s

• Prior biliary procedures or indwelling biliary stents

• Biliary strictures or malignancy of the bile ducts or pancreas

• Diabetes and multiple comorbidities — associated with worse outcomes and readmission

• History of recurrent biliary disease

• The classic gallstone risk factors — obesity, female sex, rapid weight loss, and family history (as drivers of the underlying stones)

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Bile normally flows continuously from the liver through the bile ducts into the intestine, and this flow keeps the biliary tree sterile (Perri & Raiford, Yamada's Textbook of Gastroenterology, 2022). When a stone or stricture obstructs the duct, bile stagnates and pressure rises within the biliary system (Sornsenee et al., PLoS One, 2025).

This elevated pressure forces bacteria and their toxins from the infected bile back across the duct walls into the bloodstream (a process called cholangiovenous and cholangiolymphatic reflux), which is why cholangitis can progress so quickly from a local infection to systemic sepsis (Sornsenee et al., PLoS One, 2025). The infection also seeds the liver, and if untreated can produce intrahepatic (liver) abscesses (Sornsenee et al., PLoS One, 2025). In severe disease, the systemic inflammatory response leads to hypotension, confusion, and multi-organ dysfunction — the features that define Grade III cholangitis and drive its high mortality (Martínez Márquez et al., Abdominal Radiology, 2026).

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Untreated or inadequately drained cholangitis can lead to (Sornsenee et al., PLoS One, 2025; Perri & Raiford, Yamada's Textbook of Gastroenterology, 2022):

• Sepsis and septic shock — the main cause of death

• Multi-organ failure — hypotension, kidney injury, altered mental status (features of severe disease)

• Intrahepatic (liver) abscess

• Bacteremia — bloodstream infection

• Acute kidney injury and disseminated intravascular coagulation in severe sepsis

• Death — mortality up to 30% in severe (Grade III) cases

• Recurrent biliary complications — including recurrent cholangitis, cholecystitis, and pancreatitis if the underlying stones and gallbladder are not addressed (Discolo et al., Surgical Endoscopy, 2020)

The hallmark is the combination of pain, fever, and jaundice, though the full triad is often absent (Neitzel et al., Journal of Intensive Care Medicine, 2025):

• Charcot's triad — right-upper-quadrant abdominal pain, fever (often with shaking chills), and jaundice; highly specific but present in only about 22% of patients (Neitzel et al., Journal of Intensive Care Medicine, 2025).

• Reynolds' pentad — Charcot's triad plus hypotension and altered mental status (confusion), signaling severe, life-threatening disease; occurs in only 5–7% of patients (Markotic et al., Cochrane Database, 2020).

• Fever and chills — reflecting systemic infection (Perri & Raiford, Yamada's Textbook of Gastroenterology, 2022).

• Jaundice — yellowing of the skin and eyes, often with dark urine and pale stools, from the blocked bile duct (Perri & Raiford, Yamada's Textbook of Gastroenterology, 2022).

• Right-upper-quadrant pain, nausea, and malaise (Perri & Raiford, Yamada's Textbook of Gastroenterology, 2022).

Because the classic triad is frequently incomplete, a high index of suspicion is essential — fever and/or leukocytosis with evidence of cholestasis should prompt consideration of cholangitis (Barakat et al., Gastroenterology, 2025).

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Diagnosis follows the Tokyo Guidelines 2018 (TG18), which combine three categories of findings (Neitzel et al., Journal of Intensive Care Medicine, 2025):

• Systemic inflammation — fever above 38°C and/or shaking chills, or laboratory evidence of inflammation (white blood cell count <4 or >10 ×10⁹/L, or elevated C-reactive protein) (Neitzel et al., Journal of Intensive Care Medicine, 2025).

• Cholestasis — jaundice (total bilirubin ≥2 mg/dL) or abnormal liver tests (ALP, GGT, AST, ALT >1.5× the upper limit of normal) (Neitzel et al., Journal of Intensive Care Medicine, 2025).

• Imaging — biliary dilatation, or evidence of a cause such as a stone, stricture, or stent (Neitzel et al., Journal of Intensive Care Medicine, 2025).

A definite diagnosis requires one item from each category (Neitzel et al., Journal of Intensive Care Medicine, 2025). Supporting investigations include:

• Transabdominal ultrasound — first-line imaging to assess for biliary dilatation and stones (Biesterveld & Alam, Surgical Infections, 2021).

• MRCP — accurate but time- and labor-intensive, reserved for carefully selected cases to avoid treatment delay (Biesterveld & Alam, Surgical Infections, 2021).

• Blood cultures and bile cultures — to identify the organism and tailor antibiotics, particularly important given rising rates of ESBL-producing resistant organisms (Sornsenee et al., PLoS One, 2025).

• Severity grading (TG18 Grade I–III) — based on clinical features, laboratory values, and the presence of organ dysfunction, to determine the urgency of drainage (Martínez Márquez et al., Abdominal Radiology, 2026).

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Fever, jaundice, and right-upper-quadrant pain must be distinguished from (Perri & Raiford, Yamada's Textbook of Gastroenterology, 2022; Neitzel et al., Journal of Intensive Care Medicine, 2025):

• Acute cholecystitis (and concurrent cholecystitis with cholangitis)

• Choledocholithiasis without infection

• Gallstone pancreatitis

• Liver abscess

• Acute viral or alcoholic hepatitis

• Right-lower-lobe pneumonia or sepsis from another source

• Mirizzi syndrome

• Biliary or pancreatic malignancy causing obstruction

• Primary sclerosing cholangitis with superimposed infection

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Acute cholangitis is an emergency treated in the hospital, not with lifestyle change; however, because most cases stem from gallstones, the measures that reduce gallstone formation lower the underlying risk (Markotic et al., Cochrane Database, 2020):

• Maintain a healthy weight and avoid rapid/crash weight loss — and when major weight loss is planned (including after bariatric surgery), ursodeoxycholic acid can reduce gallstone formation.

• Favor a higher-fiber, lower-refined-fat diet and manage metabolic risk factors.

Once cholangitis develops, there is no role for lifestyle or dietary management — it requires urgent antibiotics and biliary drainage, and definitive gallbladder removal afterward to prevent recurrence (Biesterveld & Alam, Surgical Infections, 2021).

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Management rests on two time-sensitive pillars — antibiotics and biliary drainage — followed by definitive treatment of the cause (Coccolini et al., WSES Guidelines, 2023):

• Resuscitation and antibiotics — IV fluids and prompt empirical broad-spectrum antibiotics targeting biliary gram-negative organisms, adjusted to severity and local resistance patterns; severe (Grade III) and healthcare-associated cases require coverage against Pseudomonas and enterococci (Buckman & Mazuski, JAMA Surgery, 2019). After successful drainage, antibiotics are typically continued for 4–7 days (Buckman & Mazuski, JAMA Surgery, 2019).

• Biliary drainage (decompression) — the cornerstone — the obstruction must be relieved to control infection; timing is dictated by severity (Martínez Márquez et al., Abdominal Radiology, 2026):

• Mild (Grade I) — drainage considered if there is no improvement within 24 hours of antibiotics and fluids.

• Moderate (Grade II) — early biliary drainage.

• Severe (Grade III) — emergency drainage alongside organ support.

• ERCP — first-line drainage — endoscopic decompression allows both drainage and stone removal (with sphincterotomy and stent placement as needed); performing ERCP within 48 hours improves outcomes, and early ERCP reduces length of stay, cost, and readmission (Barakat et al., Gastroenterology, 2025; Parikh et al., Surgical Endoscopy, 2021).

• Percutaneous transhepatic biliary drainage (PTBD) — an alternative when ERCP is not feasible or fails, including in critically ill patients or those with surgically altered anatomy (e.g., prior Roux-en-Y) (Martínez Márquez et al., Abdominal Radiology, 2026).

• EUS-guided biliary drainage (EUS-BD) — a third-line option in high-volume centers when both ERCP and PTBD are contraindicated or unsuccessful (Martínez Márquez et al., Abdominal Radiology, 2026).

• Staged treatment in sepsis — if stones cannot be cleared during initial drainage of a critically ill patient, a stent is placed first and stone removal is completed after recovery (Narula et al., Surgical Endoscopy, 2020).

• Laparoscopic cholecystectomy after recovery — in gallstone-related cholangitis, gallbladder removal should be performed after the patient recovers, ideally during the same admission, to prevent recurrent biliary complications (Biesterveld & Alam, Surgical Infections, 2021; Discolo et al., Surgical Endoscopy, 2020).

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Anyone who develops fever with jaundice (yellow eyes or skin) and upper-abdominal pain should seek emergency care immediately, because this combination strongly suggests a bile duct infection (Neitzel et al., Journal of Intensive Care Medicine, 2025). People with known gallstones, a prior history of bile duct stones, or an indwelling biliary stent are at particular risk and should be evaluated urgently for any new fever, jaundice, or dark urine (Parikh et al., Surgical Endoscopy, 2021). Cholangitis can deteriorate rapidly, so symptoms should never be observed at home (Perri & Raiford, Yamada's Textbook of Gastroenterology, 2022).

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Seek emergency care for (Neitzel et al., Journal of Intensive Care Medicine, 2025; Sornsenee et al., PLoS One, 2025):

• Fever and chills with jaundice and right-upper-quadrant pain (Charcot's triad)

• Confusion, drowsiness, or altered mental status

• Low blood pressure, lightheadedness, or a rapid heart rate — signs of sepsis (with the above, Reynolds' pentad)

• Jaundice, dark urine, or clay-colored stools with feeling unwell

• Known bile duct stones or a biliary stent with new fever

These features indicate a biliary emergency requiring immediate hospital admission, IV antibiotics, and urgent biliary drainage; delay increases the risk of sepsis and death (Coccolini et al., WSES Guidelines, 2023).

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After the infection is controlled and the obstruction relieved, the long-term outlook depends on treating the underlying cause (Discolo et al., Surgical Endoscopy, 2020). In gallstone-related cholangitis, removing the gallbladder substantially reduces the risk of recurrent biliary complications, and cholecystectomy during the index admission lowers the rate of recurrent cholangitis and other gallstone events compared with delayed surgery, where recurrence rates reach 20–25% (Discolo et al., Surgical Endoscopy, 2020). Patients whose cholangitis is due to strictures or malignancy require ongoing, cause-specific management and surveillance (Neitzel et al., Journal of Intensive Care Medicine, 2025). Once the stones and gallbladder are addressed, most patients return to normal activity and diet with an excellent long-term prognosis (Biesterveld & Alam, Surgical Infections, 2021).

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With prompt antibiotics and timely biliary drainage, most patients with mild to moderate cholangitis recover well (Martínez Márquez et al., Abdominal Radiology, 2026). Prognosis is driven by severity and the speed of treatment: severe (Grade III) disease carries a mortality as high as 30%, and delayed biliary drainage (beyond 72 hours) is associated with prolonged hospitalization, organ failure, ICU admission, and worse outcomes (Sornsenee et al., PLoS One, 2025; Parikh et al., Surgical Endoscopy, 2021). Advanced age, multiple comorbidities, diabetes, malignant obstruction, and the onset of pancreatitis are additional predictors of worse outcomes (Huang et al., EClinicalMedicine, 2024). Treatment at an experienced, high-volume center with ready access to ERCP improves results (Parikh et al., Surgical Endoscopy, 2021).

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Acute cholangitis is a true biliary emergency in which the speed and sequence of treatment directly determine survival (Martínez Márquez et al., Abdominal Radiology, 2026). As a board-certified surgeon with advanced expertise in minimally invasive and robotic foregut and biliary surgery, Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM uses Tokyo Guidelines–based severity grading to triage urgency, initiates prompt resuscitation and broad-spectrum antibiotics, and coordinates timely biliary decompression — prioritizing ERCP, with percutaneous or EUS-guided drainage when endoscopic access is not feasible (Buckman & Mazuski, JAMA Surgery, 2019; Narula et al., Surgical Endoscopy, 2020). For gallstone-related cholangitis, he performs same-admission laparoscopic (or robotic) cholecystectomy once the patient has stabilized — the strategy shown to prevent recurrent biliary complications — and adheres to safe-cholecystectomy principles to minimize the risk of bile-duct injury (Discolo et al., Surgical Endoscopy, 2020; Biesterveld & Alam, Surgical Infections, 2021). He provides multidisciplinary, high-volume biliary care for the most complex and critically ill presentations (Parikh et al., Surgical Endoscopy, 2021).

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