Which initial investigations should be performed in a patient suspected of having cholangitis?

Initial investigations for a patient suspected of having cholangitis should include:

• Liver function tests (LFTs) to assess for cholestasis and liver injury.
• Full blood count including white blood cell count to detect infection or inflammation.
• C-reactive protein (CRP) as a marker of inflammation.
• Blood cultures to identify causative organisms if sepsis is suspected.
• Abdominal ultrasound to evaluate the biliary tree for dilation, stones, or obstruction.
• Consider magnetic resonance cholangiopancreatography (MRCP) if ultrasound is inconclusive but clinical suspicion remains high, especially if bile duct dilation or abnormal LFTs are present.

These investigations help confirm the diagnosis, assess severity, and guide further management including the need for hospital admission and possible intervention.

References: These recommendations align with the Tokyo guideline TG13 flowchart for acute cholangitis and cholecystitis management and NICE guidance on gallstone disease diagnosis and management ¹,⁵.