Fact-sheet: Acute cholangitis
Updated on 02/23/2026 at 2:49 PM
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Definition
Infection of the bile ducts by anaerobic gut organisms.
Most often caused by mechanical obstruction of the bile ducts:
- 90% due to a calculus
- Tumor of the intra- and extrahepatic bile ducts, liver tumor, pancreatic tumor, or ampulla of Vater tumor
- Parasitic (ascariasis, liver fluke)
- Iatrogenic (catheterization)
- Bile duct malformation
- Cholangitis
- Caroli disease
Separately: LPAC syndrome: autosomal recessive genetic disease, responsible for an abnormality of lipid metabolism.
Bile lithogenic and saturated with cholesterol.
Clinical features
Charcot's triad -right upper quadrant pain -fever -jaundice Diagnostic criteria (2 out of 3) -biliary symptoms before age 40 -recurrence of biliary lithiasis after cholecystectomy -intrahepatic bile duct calculi or cholesterol impaction within the intrahepatic bile ducts (comet-tail ultrasound artifacts)
Laboratory findings
Icteric cholestasis:
- Increased total bilirubin, particularly the conjugated fraction
- Increased alkaline phosphatase
Inflammatory syndrome with leukocytosis
Possible pancreatic reaction with hyperlipasemia
Followed by hepatic cytolysis and systemic reaction that may progress to multiorgan failure syndrome
Radiography
Plain abdominal radiograph not performed in this context, can rarely demonstrate large radiopaque calculi.
Pneumobilia is exceptional
Ultrasound
Direct signs: - Common bile duct calculi visualized in 40% of cases - Dilation of the extrahepatic and intrahepatic common bile duct, however, inconstant. (>7mm if gallbladder in place, >9mm after cholecystectomy) - Possible wall thickening Indirect signs: - Mobile gallbladder calculi - Biliary abscesses
CT
Useful for positive, etiologic, differential diagnosis and for detecting complications:
Without injection:
- Radiopaque lithiasis
- Pneumobilia if anaerobic organisms
- Dilation of the bile ducts upstream of the obstruction, thin caliber downstream
With injection:
- Dilation of the bile ducts
- Wall thickening
- Bile duct enhancement
- Peripheral hepatic hyperemia around the bile ducts
Demonstration of the obstruction and its nature
Demonstration of complications: hepatic abscess, pancreatitis and acute cholecystitis.
MRI
Useful for etiologic diagnosis if CT is noncontributory:
- Dilation of the bile ducts
- Obstruction due to bile duct lithiasis (rounded image, signal void on T2, variable on T1) with cupuliform cutoff
- Other obstructions
Delineates anatomic variants of the bile ducts, pancreatic duct and cystic duct
Management
Depending on the etiology:
If lithiasic: therapeutic ERCP and cholecystectomy