Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Acute cholangitis

Nezam H Afdhal, MD, FRCPI
Section Editors
Sanjiv Chopra, MD, MACP
Stephen B Calderwood, MD
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF


Acute cholangitis is a clinical syndrome characterized by fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract. It is also referred to as ascending cholangitis. Cholangitis was first described by Charcot as a serious and life-threatening illness; however, it is now recognized that the severity can range from mild to life-threatening [1].

This topic will review the clinical features, diagnosis, and management of acute cholangitis. The approach to patients with primary sclerosing cholangitis, the management of common bile duct stones, and the endoscopic management of malignant biliary obstructions are discussed in detail elsewhere. (See "Primary sclerosing cholangitis in adults: Clinical manifestations and diagnosis" and "Primary sclerosing cholangitis in adults: Management" and "Endoscopic management of bile duct stones: Standard techniques and mechanical lithotripsy" and "Endoscopic stenting for malignant pancreaticobiliary obstruction".)


Acute cholangitis is caused primarily by bacterial infection in a patient with biliary obstruction. The organisms typically ascend from the duodenum; hematogenous spread from the portal vein is a rare source of infection [2].

The most important predisposing factor for acute cholangitis is biliary obstruction and stasis. The most common causes of biliary obstruction in patients with acute cholangitis without bile duct stents are biliary calculi (28 to 70 percent), benign stenosis (5 to 28 percent), and malignancy (10 to 57 percent) [3]. In addition, acute cholangitis is a common complication of stent placement for malignant biliary obstruction (18 percent in one series) [4].

Mechanism of bacterial entry into the biliary tract — Bacteria are able to enter the biliary tract when the normal barrier mechanisms are disrupted. This may result in translocation of bacteria from the portal system or duodenum into the biliary tree.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Mar 18, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Boey JH, Way LW. Acute cholangitis. Ann Surg 1980; 191:264.
  2. Sung JY, Costerton JW, Shaffer EA. Defense system in the biliary tract against bacterial infection. Dig Dis Sci 1992; 37:689.
  3. Kimura Y, Takada T, Kawarada Y, et al. Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007; 14:15.
  4. Huibregtse K, Carr-Locke DL, Cremer M, et al. Biliary stent occlusion--a problem solved with self-expanding metal stents? European Wallstent Study Group. Endoscopy 1992; 24:391.
  5. Csendes A, Becerra M, Burdiles P, et al. Bacteriological studies of bile from the gallbladder in patients with carcinoma of the gallbladder, cholelithiasis, common bile duct stones and no gallstones disease. Eur J Surg 1994; 160:363.
  6. Ohdan H, Oshiro H, Yamamoto Y, et al. Bacteriological investigation of bile in patients with cholelithiasis. Surg Today 1993; 23:390.
  7. Leung JW, Sung JY, Costerton JW. Bacteriological and electron microscopy examination of brown pigment stones. J Clin Microbiol 1989; 27:915.
  8. van den Hazel SJ, Speelman P, Tytgat GN, et al. Role of antibiotics in the treatment and prevention of acute and recurrent cholangitis. Clin Infect Dis 1994; 19:279.
  9. Saik RP, Greenburg AG, Farris JM, Peskin GW. Spectrum of cholangitis. Am J Surg 1975; 130:143.
  10. DenBesten L, Doty JE. Pathogenesis and management of choledocholithiasis. Surg Clin North Am 1981; 61:893.
  11. Mosler P. Diagnosis and management of acute cholangitis. Curr Gastroenterol Rep 2011; 13:166.
  12. Attasaranya S, Fogel EL, Lehman GA. Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis. Med Clin North Am 2008; 92:925.
  13. Kiriyama S, Takada T, Strasberg SM, et al. TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci 2013; 20:24.
  14. Negm AA, Schott A, Vonberg RP, et al. Routine bile collection for microbiological analysis during cholangiography and its impact on the management of cholangitis. Gastrointest Endosc 2010; 72:284.
  15. Chan YL, Chan AC, Lam WW, et al. Choledocholithiasis: comparison of MR cholangiography and endoscopic retrograde cholangiography. Radiology 1996; 200:85.
  16. Lee MG, Lee HJ, Kim MH, et al. Extrahepatic biliary diseases: 3D MR cholangiopancreatography compared with endoscopic retrograde cholangiopancreatography. Radiology 1997; 202:663.
  17. Soto JA, Yucel EK, Barish MA, et al. MR cholangiopancreatography after unsuccessful or incomplete ERCP. Radiology 1996; 199:91.
  18. Leung JW, Ling TK, Chan RC, et al. Antibiotics, biliary sepsis, and bile duct stones. Gastrointest Endosc 1994; 40:716.
  19. Sinanan MN. Acute cholangitis. Infect Dis Clin North Am 1992; 6:571.
  20. Sung JJ, Lyon DJ, Suen R, et al. Intravenous ciprofloxacin as treatment for patients with acute suppurative cholangitis: a randomized, controlled clinical trial. J Antimicrob Chemother 1995; 35:855.
  21. Gerecht WB, Henry NK, Hoffman WW, et al. Prospective randomized comparison of mezlocillin therapy alone with combined ampicillin and gentamicin therapy for patients with cholangitis. Arch Intern Med 1989; 149:1279.
  22. Hui CK, Lai KC, Yuen MF, et al. Acute cholangitis--predictive factors for emergency ERCP. Aliment Pharmacol Ther 2001; 15:1633.
  23. Salek J, Livote E, Sideridis K, Bank S. Analysis of risk factors predictive of early mortality and urgent ERCP in acute cholangitis. J Clin Gastroenterol 2009; 43:171.
  24. Yeom DH, Oh HJ, Son YW, Kim TH. What are the risk factors for acute suppurative cholangitis caused by common bile duct stones? Gut Liver 2010; 4:363.
  25. Lai EC, Mok FP, Tan ES, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med 1992; 326:1582.
  26. Chijiiwa K, Kozaki N, Naito T, et al. Treatment of choice for choledocholithiasis in patients with acute obstructive suppurative cholangitis and liver cirrhosis. Am J Surg 1995; 170:356.
  27. Leese T, Neoptolemos JP, Baker AR, Carr-Locke DL. Management of acute cholangitis and the impact of endoscopic sphincterotomy. Br J Surg 1986; 73:988.
  28. Lai EC, Tam PC, Paterson IA, et al. Emergency surgery for severe acute cholangitis. The high-risk patients. Ann Surg 1990; 211:55.
  29. Leung JW, Cotton PB. Endoscopic nasobiliary catheter drainage in biliary and pancreatic disease. Am J Gastroenterol 1991; 86:389.
  30. Lee DW, Chan AC, Lam YH, et al. Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: a prospective randomized trial. Gastrointest Endosc 2002; 56:361.
  31. Hui CK, Lai KC, Yuen MF, et al. Does the addition of endoscopic sphincterotomy to stent insertion improve drainage of the bile duct in acute suppurative cholangitis? Gastrointest Endosc 2003; 58:500.
  32. Andrew DJ, Johnson SE. Acute suppurative cholangitis, a medical and surgical emergency. A review of ten years experience emphasizing early recognition. Am J Gastroenterol 1970; 54:141.
  33. Shimada H, Nakagawara G, Kobayashi M, et al. Pathogenesis and clinical features of acute cholangitis accompanied by shock. Jpn J Surg 1984; 14:269.
  34. Csendes A, Diaz JC, Burdiles P, et al. Risk factors and classification of acute suppurative cholangitis. Br J Surg 1992; 79:655.
  35. Himal HS, Lindsay T. Ascending cholangitis: surgery versus endoscopic or percutaneous drainage. Surgery 1990; 108:629.
  36. Thompson JE Jr, Pitt HA, Doty JE, et al. Broad spectrum penicillin as an adequate therapy for acute cholangitis. Surg Gynecol Obstet 1990; 171:275.
  37. Tai DI, Shen FH, Liaw YF. Abnormal pre-drainage serum creatinine as a prognostic indicator in acute cholangitis. Hepatogastroenterology 1992; 39:47.
  38. Thompson J, Bennion RS, Pitt HA. An analysis of infectious failures in acute cholangitis. HPB Surg 1994; 8:139.
  39. Liu TJ. Acute biliary septic shock. HPB Surg 1990; 2:177.