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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Ascending cholangitis = bacterial infection of obstructed biliary tree — a surgical emergency
- Charcot's triad: RUQ pain + jaundice + fever/rigors (present in ~50–70%)
- Reynolds' pentad: Charcot's triad + hypotension + confusion (severe, life-threatening)
- Commonest cause: CBD stone. Other causes: malignant biliary obstruction, post-ERCP, biliary stent occlusion
- Management: IV antibiotics + urgent biliary drainage (ERCP within 24–72 hours)
Overview
Ascending cholangitis is an acute bacterial infection of the biliary system, almost always occurring in the context of biliary obstruction. Obstruction leads to biliary stasis, bacterial colonisation (usually E. coli, Klebsiella, Enterococcus), and ascending infection. The commonest cause is choledocholithiasis (CBD stones). Other causes include malignant biliary strictures (cholangiocarcinoma, pancreatic head tumour), benign strictures, and post-procedural (ERCP, biliary stent occlusion). Without prompt biliary drainage, cholangitis rapidly progresses to biliary sepsis, multiorgan failure, and death.
Epidemiology
Ascending cholangitis is the most serious acute complication of gallstone disease. It accounts for a significant proportion of emergency biliary admissions. Mortality has decreased with early ERCP but remains 5–10% overall, rising to 30–50% if untreated or if Reynolds' pentad present. Risk factors include previous biliary surgery or instrumentation, biliary stents, and choledocholithiasis.
Clinical Features
Symptoms
RUQ pain (can be severe)
Jaundice (usually obstructive pattern)
High fever with rigors (swinging pyrexia)
Dark urine and pale stools (obstructive jaundice)
Confusion (severe cholangitis — Reynolds' pentad)
Nausea and vomiting
Signs
RUQ tenderness
Pyrexia (often spiking/swinging)
Jaundice (clinically visible when bilirubin >40 µmol/L)
Tachycardia and hypotension (septic shock — Reynolds' pentad)
Altered mental state (severe sepsis)
Investigations
First-line
BloodsFBC (leucocytosis), CRP (markedly raised), LFTs (obstructive pattern: raised bilirubin, ALP, GGT >> raised ALT/AST), U&Es, clotting (coagulopathy in sepsis/liver dysfunction)
Blood culturesESSENTIAL — take before starting antibiotics. Most commonly grow E. coli, Klebsiella, or Enterococcus
Abdominal ultrasoundDilated CBD (>7 mm, or >10 mm post-cholecystectomy), gallstones. May not always visualise the stone in distal CBD
Second-line
MRCPIf USS confirms dilated CBD but stone not visualised — non-invasive mapping of biliary tree before ERCP
Lactate and ABG/VBGAssess severity of sepsis — raised lactate indicates tissue hypoperfusion
Specialist
ERCPDiagnostic AND therapeutic: sphincterotomy + stone extraction + biliary stenting if incomplete clearance. Should be performed urgently (within 24–72 h, within 24 h if severe)
Percutaneous transhepatic cholangiography (PTC)If ERCP fails or inaccessible (e.g. altered anatomy post-gastrectomy) — allows external biliary drainage
Management
NICE CG188 and Tokyo Guidelines 20181
Resuscitation and antibiotics
- Sepsis 6: take blood cultures, measure lactate, give IV antibiotics, give IV fluids, measure urine output, give oxygen if needed
- IV antibiotics: piperacillin-tazobactam 4.5 g TDS or co-amoxiclav 1.2 g TDS + gentamicin (per local protocol)
- Aggressive IV fluid resuscitation
- Correct coagulopathy (vitamin K, FFP) before any intervention
2
Biliary drainage
- Urgent ERCP: within 24 hours if severe (Reynolds' pentad, failure to respond to antibiotics)
- ERCP within 72 hours for moderate cholangitis
- Sphincterotomy + balloon/basket stone extraction
- If CBD cannot be cleared completely: temporary biliary stent to maintain drainage
3
Definitive treatment
- Cholecystectomy once recovered from acute episode (if gallstone aetiology)
- If malignant obstruction: biliary stenting (metallic) ± oncological management
- Interval ERCP if residual stones after initial drainage
Complications
- Biliary sepsis and septic shock: Multiorgan failure — mortality 30–50% if Reynolds' pentad
- Liver abscess: From ascending infection into hepatic parenchyma
- Acute kidney injury: From sepsis and hypotension
- DIC: In severe biliary sepsis
- Recurrent cholangitis: If source of obstruction not definitively managed
UKMLA Exam Tips
- 1Charcot's triad: RUQ pain + jaundice + fever = ascending cholangitis
- 2Reynolds' pentad: Charcot's triad + hypotension + confusion = severe cholangitis with septic shock
- 3Obstructive LFT pattern: raised ALP and bilirubin >> raised transaminases (ALT/AST)
- 4ERCP is the definitive treatment — both diagnostic and therapeutic. Always do ERCP, not just antibiotics
- 5Commonest organisms: E. coli, Klebsiella, Enterococcus — hence broad-spectrum Gram-negative cover essential
- 6Acute cholangitis is different from primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) — these are autoimmune, not infective
practicetest your knowledge on ascending cholangitisApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — gastroenterology and beyond.
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