Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or reperfusion when indicated; document follow‑up and patient education.
Algorithm
- Recognize cholangitis: fever/systemic inflammation + cholestasis + imaging evidence of obstruction.
- Resuscitate with crystalloids; obtain cultures; start broad‑spectrum antibiotics.
- Risk‑grade (Tokyo): Grade I (mild) vs II (moderate) vs III (severe organ dysfunction).
- Plan biliary drainage: Grade II–III → urgent ERCP (often within 24 h) after initial stabilization; Grade I → early ERCP.
- Address source (stone extraction/stent) and complications (abscess); de‑escalate antibiotics by culture.
- Arrange cholecystectomy for gallstone etiology after recovery; follow cholestasis labs.
Clinical Synopsis & Reasoning
Systemic inflammation + cholestasis + imaging define diagnosis. Start early broad‑spectrum antibiotics and fluids; perform ERCP drainage urgently for Grade II–III disease and after stabilization for Grade I; tailor timing to sepsis severity and comorbidity.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Ultrasound | First‑line imaging | Bile duct dilation, stones | Fast and bedside |
| CT/MRCP (when needed) | Extent/complications | Obstruction, abscess | Guide drainage route |
| Bilirubin/alk phos/GGT | Cholestasis | Elevated | Trend with therapy |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Piperacillin–tazobactam | β‑lactam/β‑lactamase inhibitor | Hours | Empiric broad‑spectrum | Renal dosing |
| Ceftriaxone + Metronidazole | Cephalosporin + nitroimidazole | Hours | Alternative coverage | Local resistance awareness |
| Carbapenem (e.g., meropenem) | Carbapenem | Hours | Severe/resistant cases | Reserve for MDR risk |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.