Ascending Cholangitis

Ascending cholangitis: bacterial infection of the biliary tree, usually from CBD stone obstruction. Charcot's triad: fever/rigors, jaundice, RUQ pain (60%). Reynold's pentad = Charcot's + hypotension + altered consciousness = severe. Tokyo…

Tokyo Guidelines (TG18)

The pathway

1 · Recognise & grade severity

Charcot's triad: RUQ pain, fever >38°C, jaundice
Grade III (severe): BP <90, confusion, AKI (Cr >2x normal), bilirubin >85, platelet <100
Grade II (moderate): WBC >12 or <4, fever >39°C, age >75, bili >85, albumin <0.7x LLN
Grade I: neither II nor III

2 · IV access & resuscitation

2 wide-bore IV cannulae
Fluid resuscitation: 500ml crystalloid bolus if hypotensive
Bloods: FBC, CRP, LFTs (bilirubin, ALP, GGT elevated), blood cultures x2 before antibiotics, coagulation, cross-match

3 · Empirical antibiotics

Start within 1 hour of diagnosis: piperacillin-tazobactam 4.5g IV (or meropenem if penicillin allergy/immunocompromised). Cover gram-negatives (E. coli, Klebsiella) and anaerobes. Follow local trust guidelines. Duration guided by clinical response.

4 · Imaging

USS abdomen: CBD dilation (>6mm), stones, gallbladder inflammation
MRCP if USS equivocal — best non-invasive for CBD stones
CT if diagnosis unclear or to exclude perforation
Avoid contrast CT in AKI unless necessary

5 · Biliary drainage — ERCP

Grade I/II: ERCP within 24–48h
Grade III (septic shock): emergency ERCP within 24h or urgent drainage — biliary stent or percutaneous transhepatic drainage (PTD) if ERCP not possible
Sphincterotomy and stone extraction at ERCP
Elective cholecystectomy after recovery

6 · Post-ERCP monitoring

Post-ERCP complications: pancreatitis, perforation, haemorrhage, cholangitis worsening. Monitor: bilirubin trend (should fall), temperature, WBC. If not improving 48h after ERCP — consider residual stones, resistant organism, or biliary stricture.

Drugs

Drug	Dose	Route	Notes
Piperacillin-tazobactam	4.5g 8-hourly	IV	Start within 1h. Covers gram-negatives and anaerobes. Check local guideline.
Meropenem	1g 8-hourly	IV	If penicillin allergy, severe sepsis, or resistant organisms.
IV crystalloid	500ml bolus	IV	Aggressive resuscitation in Grade III. Monitor UO, lactate, HR, BP.

When to escalate

Grade III (Reynold's pentad: shock + confusion) → ITU + emergency biliary drainage,No response to antibiotics at 12–24h → escalate antibiotics, urgent ERCP,ERCP not possible → percutaneous transhepatic drainage (PTD) by IR,Developing AKI → nephrology, contrast caution,Coagulopathy (INR >1.5) before ERCP → fresh frozen plasma, vitamin K

Reference: Tokyo Guidelines TG18 — Management of Acute Cholangitis 2018

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