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    Ascending Cholangitis


    Last Updated Jan 19, 2022
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    • Ascending cholangitis (AC) is a clinical syndrome resulting from biliary obstruction and bacterial growth in the bile.
    • Most frequent cause of biliary obstruction is choledocholithiasis, but other causes include post-ERCP, benign or malignant strictures, and sclerosing cholangitis.
    • Elevated intraductal pressure from obstruction allows for cholangio-venous reflux and translocation of bacteria into vascular system.
    • Early diagnosis and prompt source control/antimicrobial therapy are critical in limiting incidence of septic shock and multiple organ failure.

    Clinical Presentation

    • Classic triad of fever, jaundice, and RUQ/abdominal pain although absence of abdominal pain does not exclude diagnosis of AC.
    • Milder cases may mimic acute cholecystitis.
    • Maintain suspicion of AC in unspecified sepsis with possible abdominal source.

    Empiric Therapy / Initial Laboratory Investigations

    • Initial bloodwork should include liver enzymes, C-reactive protein (CRP) and serum lactate.
    • Draw blood cultures x2 in all cases of suspected AC.
    • Empiric therapy should be administered as soon as diagnosis of AC is suspected.


    • First-line imaging should be abdominal ultrasound to confirm stones or bile duct dilatation.
    • If formal ultrasonography unavailable OR abdominal U/S is normal in suspected AC, proceed directly to abdominal CT if available.
    • If above studies do not yield definite diagnosis, consider early consultation and possible transfer for magnetic resonance cholangiopancreatography (MRCP).

    2018 Tokyo Guidelines Diagnostic Criteria

    • Definite diagnosis includes ALL of the following:
      • Systemic inflammation
        • A-1 Fever and/or shaking chills, OR
        • A-2 WBC <4 or >10 or CRP >1
      • Cholestasis
        • B-1 Jaundice, OR
        • B-2 Liver enzymes > 1.5 x STD
      • Imaging
        • C-1 Biliary dilatation, OR
        • C-2 Evidence of etiology on imaging (stricture, stone, stent etc.)
    • Sensitive (91.8%) but false positives (5.9%) include acute cholecystitis.
    • Limited ability to diagnose milder cases.

    Severity Grading

    • Grade I (mild) acute cholangitis does not meet Grade II/III criteria at time of diagnosis but can rapidly progress.
    • Grade II (moderate) acute cholangitis with two of the following conditions:
      • WBC > 12,000/mm3 or < 4,000/mm3
      • T > 39C
      • Age > 75 years old
      • Total bilirubin > 85.5 umol/L
      • Serum albumin < 0.7 x STD
    • Grade III (severe) acute cholangitis with end-organ dysfunction, including any of the following:
      • Cardiovascular: hypotension requiring dopamine >5 ug/kg per min or NEP
      • Neurological: altered level of consciousness
      • Respiratory: PaO2/FiO2 <300
      • Renal: oliguria or serum Cr > 188 umol/L
      • Hepatic: PT-INR > 1.5
      • Hematologic: Platelet < 100,000/mm3
    • 30-day all-cause mortality rates are 2.4%, 4.7% and 8.4% by severity grades I-III respectively.

    Antimicrobial Therapy

    • Common microorganisms include:
      • Escherichia coli (31-44%)
      • Klebsiella (9-20%)
      • Pseudomonas (0.5-19%)
      • Enterobacter (5-9%)
      • Enterococcus (3-34%)
      • Streptococcus (2-10%)
    • For Grade I disease, start with Ceftriaxone 1-2g IV q24h +/- Metronidazole 500mg IV/PO q12h.
    • If beta lactam allergy, use Ciprofloxacin 400mg IV q12h instead.
    • For Grade II/III disease, start with Piperacillin-tazobactam 3.375g IV q6h
      • If suspect Pseudomonas, use Piperacillin-tazobactam 4.5g IV q6h
      • If extended-spectrum beta lactamase (ESBL) risk factors, use Meropenem 500mg IV q6h instead
    • If Grade III or healthcare associated AC, consider adding Vancomycin; If known VRE, switch to Linezolid 600mg IV/PO q12h.
    • Duration of antimicrobial therapy for 4-7 days after source control
      • If gram positive cocci (enterococcus, streptococcus), minimum 2 weeks recommended.
      • If hepatic abscess, continue antimicrobial therapy until complete resolution.


    • All AC require admission, antimicrobial therapy, and fluid management +/- GI/general surgery.
    • Grade I:
      • Transfer for biliary drainage if they fail to respond to initial treatment within 24h.
      • If high risk of choledocholithiasis, consult GI/general surgery for likely ERCP with elective cholecystectomy.
      • If moderate risk of choledocholithiasis, consider GI/general surgery consultation for MRCP first.
    • Grade II:
      • Early consultation with GI/general surgery for early biliary drainage within 24-48h.
      • Clinicians must maintain low threshold to initiate necessary cardiorespiratory support.
    • Grade III:
      • Urgent early consultation with intensivist and high priority transfer to hospital that is equipped to perform ERCP/percutaneous biliary drainage and/or critical care.

    Quality Of Evidence?


    • Mortality benefit of early drainage in Grade II disease: Multiple case series studies.
    • Diagnostic criteria: Two retrospective case series studies have shown sensitivity as screening tool, but no studies have evaluated for specificity.
    • Duration of antimicrobial therapy: Based primarily on expert opinion.

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