The Bottom Line:
Cholangitis has a wide spectrum of clinical presentation ranging from mild, intermittent pain to life-threatening septic shock.
- Classic presentation is right upper quadrant pain and tenderness on palpation, jaundice, and fever and/or shaking chills (Charcot triad).
- Additional signs and symptoms associated with sepsis may also be present.
- Cholangitis can be diagnosed in the presence of systemic inflammation plus cholestasis plus compatible imaging findings (Strong recommendation).
- Systemic inflammation can be demonstrated by any of
- fever and/or shaking chills
- abnormal white blood cell count, or
- an elevated C-reactive protein.
- Cholestasis can be demonstrated by any of
- jaundice or total bilirubin ≥ 2 mg/dL (34.2 mcmol/L), or
- > 1.5 times the upper limit of normal values for alkaline phosphate, gamma-glutamyl transferase, alanine aminotransferase, or aspartate aminotransferase.
- Compatible imaging findings include either
- intrahepatic biliary dilatation or
- visualization of stricture, stone, stent, or other cause of obstruction.
- Severity of the initial presentation of acute cholangitis is divided into
- mild, in which cholangitis is present but does not meet criteria for moderate or severe
- moderate, defined as the presence of any two of
- age > 75 years
- white blood cell count of > 12,000/mcL or < 4,000/mcL
- fever > 39 degrees C (102.2 degrees F)
- total bilirubin ≥ 5 mg/dL [85.5 mcmol/L]
- serum albumin < 0.7 x lower limit of normal
- severe, defined as any organ dysfunction, such as
- hypotension
- altered consciousness
- PaO2/FiO2 < 300
- serum creatinine > 2 mg/dL or oliguria
- international normalized ratio of > 1.5 (evidence of liver dysfunction)
- platelet count < 100,000/mcL
Management:
- Empiric broad-spectrum antibiotics are indicated for all patients with definite or suspected cholangitis (Strong recommendation), consider giving antibiotics and/or intravenous fluid as soon as possible if indicated.
- Biliary drainage depends on the assessment of disease severity, which may change after the initial evaluation.
See also: Treatment Options
DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. T116403, Acute Cholangitis; [updated 2018 Dec 04, cited 2021 Sept 28]. Registration and login required.
Elsevier Point of Care Clinical Overview. Philadelphia (PA): Elsevier. Cholangitis; [updated 2021 June 30, cited 2021 Sept 28].
The Bottom Line 