Ascending cholangitis is a bacterial infection of the bile ducts that happens when the flow of bile is blocked, most often by a gallstone. It can quickly lead to sepsis, so it needs antibiotics and urgent drainage of the duct.
Key symptoms
- Fever and shaking chills
- Pain in the right upper belly
- Yellow skin and eyes, dark urine and pale stools
- Confusion or feeling faint in severe cases
What you find on exam
- Fever, fast heart rate and possibly low blood pressure
- Jaundice of the eyes and skin
- Tenderness in the right upper quadrant
- Altered mental status as a sign of severe disease
Tests
- Blood count, liver tests with high bilirubin and alkaline phosphatase
- Blood cultures and lactate
- Ultrasound to look for a dilated bile duct or stones
- MRCP if the cause is unclear before drainage
Treatment basics
- IV fluids and close monitoring for sepsis
- Broad-spectrum IV antibiotics such as piperacillin-tazobactam
- Urgent bile duct drainage with ERCP and stone removal
- Gallbladder removal later if gallstones were the cause
Red flags
- Low blood pressure or signs of shock
- Confusion or decreased level of consciousness
- No improvement within a day of antibiotics
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.