Acute cholangitis

Acute cholangitis is a potentially life-threatening condition where prompt diagnosis, resuscitation, and initial decision-making are crucial for optimal outcomes1. The classical triad of fever, abdominal pain, and jaundice results from total or partial occlusion of the bile duct, leading to ascending bacterial cholangitis2. The severity of cholangitis varies from mild, which responds to antibiotics and supportive care, to severe cases with septic shock requiring urgent biliary decompression. Initial management should include empiric antimicrobial therapy, severity assessment, and imaging to guide further management and biliary drainage1,3. Endoscopic retrograde cholangiopancreatography (ERCP) has a key role in relieving biliary obstruction, with percutaneous transhepatic cholangiography (PTC) and endoscopic ultrasound (EUS) guided drainage serving as alternatives when ERCP is not feasible4–7. The choice of technique and optimal timing of drainage depend on patient anatomy, underlying cause, disease severity, and institutional capabilities. Ascending bacterial cholangitis occurs in a setting of impaired biliary flow and bacterial colonization of the bile ducts, usually from the small bowel. The most common causes include bile duct stones and/or sludge in the common bile duct, along with malignant obstructions2. Bacterial cholangitis may also develop as a complication following previous endoscopic biliary interventions, such as post-ERCP cholangitis and biliary stent dysfunction2. Surgical complications, including postoperative bile duct injury and anastomosis stricture following liver resection or transplantation, are additional predisposing factors. Benign biliary strictures, although less common, can arise from conditions such as primary sclerosing cholangitis, chronic pancreatitis and congenital malformations. Underlying conditions in acute bacterial cholangitis are summarized in Table 1.