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Acute Cholangitis

  • Author: Timothy M Scott, DO; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
Updated: Dec 27, 2015


Acute cholangitis is a bacterial infection superimposed on an obstruction of the biliary tree most commonly from a gallstone, but it may be associated with neoplasm or stricture.



The main factors in the pathogenesis of acute cholangitis are biliary tract obstruction, elevated intraluminal pressure, and infection of bile. A biliary system that is colonized by bacteria but is unobstructed, typically does not result in cholangitis. It is believed that biliary obstruction diminishes host antibacterial defenses, causes immune dysfunction, and subsequently increases small bowel bacterial colonization. Although the exact mechanism is unclear, it is believed that bacteria gain access to the biliary tree by retrograde ascent from the duodenum or from portal venous blood. As a result, infection ascends into the hepatic ducts, causing serious infection. Increased biliary pressure pushes the infection into the biliary canaliculi, hepatic veins, and perihepatic lymphatics, leading to bacteremia (25-40%). The infection can be suppurative in the biliary tract.

The bile is normally sterile. In the presence of gallbladder or common duct stones (CBD), however, the incidence of bactibilia increases. The most common organisms isolated in bile are Escherichia coli (27%), Klebsiella species (16%), Enterococcus species (15%), Streptococcus species (8%), Enterobacter species (7%), and Pseudomonas aeruginosa (7%). Organisms isolated from blood cultures are similar to those found in the bile. The most common pathogens isolated in blood cultures are E coli (59%), Klebsiella species (16%), Pseudomonas aeruginosa (5%), and Enterococcus species (4%). In addition, polymicrobial infection is commonly found in bile cultures (30-87%) and less frequent in blood cultures (6-16%). For related pathophysiology, please see the Cholelithiasis and Cholecystitis and Biliary Colic articles.

Primary sclerosing cholangitis is a chronic liver disease that is thought to be due to an autoimmune mechanism.[1] It is characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts. This condition ultimately leads to portal hypertension and cirrhosis of the liver with the only definitive treatment being a liver transplant.[2] For more on this condition, please refer to the Primary Sclerosing Cholangitis article.




United States

Cholangitis is relatively uncommon. It occurs in association with other diseases that cause biliary obstruction and bactibilia (eg, after endoscopic retrograde cholangiopancreatography [ERCP], 1-3% of patients develop cholangitis). Risk is increased if dye is injected retrograde.


Recurrent pyogenic cholangitis, sometimes referred to as Oriental cholangiohepatitis, is endemic to Southeast Asia. It is characterized by multiple occurrences of biliary tract infection, intrahepatic and extrahepatic biliary stone formation, hepatic abscesses, and dilatation and stricturing of the intrahepatic and extrahepatic bile duct.[3] For more on this condition, please refer to the Recurrent Pyogenic Cholangitis article.



The prognosis depends on several factors, including the following[4] :

  • Early recognition and treatment of cholangitis
  • Response to therapy
  • Underlying medical conditions of the patient

Mortality rate ranges from 5-10%, with a higher mortality rate in patients who require emergency decompression or surgery.

In patients responding to antibiotic therapy, the prognosis is good.


Mortality from cholangitis is high due to the predisposition in people with underlying disease. Historically, the mortality rate was 100%. With the advent of endoscopic retrograde cholangiography, therapeutic endoscopic sphincterotomy, stone extraction, and biliary stenting, the mortality rate has significantly declined to approximately 5-10%.

The following patient characteristics are associated with higher morbidity and mortality rates:

Advanced age, concurrent medical problems, and delay in decompression increase the emergent operative mortality rate (17-40%).

The mortality rate of elective surgery after medical stabilization is significantly less (approximately 3%).

In the past, suppurative cholangitis was thought to have increased morbidity; however, prospective studies have not found this to be true.


Patients are increasingly likely to have complications with greater degrees of illness, as follows:

Catheter-related problems in patients treated with percutaneous or endoscopic drainage include the following:

  • Bleeding (intra-abdominally or percutaneously)
  • Catheter-related sepsis
  • Fistulae
  • Bile leak (intraperitoneally or percutaneously)


Cholangitis frequently occurs secondary to a gallstone obstructing the common bile duct. Therefore, it carries the same risk factors as that of cholelithiasis.

Prevalence of gallstones is highest in fair-skinned people of Northern European descent as well as in Hispanic populations, Native Americans, and Pima Indians.

In addition, certain Asian populations and inhabitants of countries where intestinal parasites are common are also at increased risk. Asians are more likely to have primary stones due to chronic biliary infections, parasites, bile stasis, and biliary strictures. Recurrent pyogenic cholangitis (Oriental cholangiohepatitis) rarely is observed in the United States.

Black individuals with sickle cell disease are at increased risk.


Although gallstones are more common in women than in men, the male-to-female ratio is equal in cholangitis.


Elderly patients are more likely to progress from asymptomatic gallstones to serious complications of gallstones and cholangitis.

Suspect cholangitis in older patients presenting with sepsis and mental status changes. Elderly patients are more prone to gallstones and CBD stones and, therefore, cholangitis.

The median age at presentation is between 50 and 60 years.

Contributor Information and Disclosures

Timothy M Scott, DO Chief Resident, Department of Emergency Medicine, Detroit Medical Center, Wayne State University School of Medicine

Timothy M Scott, DO is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Osteopathic Association, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.


Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.


Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Jeffrey A Manko, MD A ssistant Professor of Emergency Medicine, Director, Emergency Medicine Residency Program, Consulting Staff, Emergency Medicine Services, New York University/Bellevue Medical Center

Jeffrey A Manko, MD is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sally Santen, MD Program Director, Assistant Professor, Department of Emergency Medicine, Vanderbilt University

Sally Santen, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Sonogram of dilated intrahepatic ducts.
CT scan of common bile duct occluded by stone. Image courtesy of David Schwartz, MD, New York University Hospital.
CT scan of 1-cm dilated common bile duct at portal triad. Image courtesy of David Schwartz, MD, New York University Hospital.
CT scan of dilated intrahepatic bile ducts. Image courtesy of David Schwartz, MD, New York University Hospital.
Algorithm for management of patients with acute cholangitis.
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