Acute Cholangitis — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] TG18 diagnosis
   Does it meet TG18 diagnosis (A systemic inflammation + B cholestasis + C imaging)? (A systemic inflammation (fever/chills, abnormal inflammatory markers); B cholestasis (jaundice T-bil ≥2 mg/dL, abnormal liver tests); C imaging (biliary dilation, cause such as stone/stricture/stent). Suspected = A + (B or C); definite = A + B + C. Charcot's triad (fever, jaundice, RUQ pain) has low sensitivity but high specificity.)
   • Suspected / definite cholangitis → TG18 severity grade
   • Does not meet → Does not meet
2. [End] Does not meet
   Evaluate other causes of RUQ pain/jaundice (cholecystitis, hepatitis, pancreatitis, perforated peptic ulcer, etc.) and manage along the appropriate pathway.
3. [Decision] TG18 severity grade
   TG18 severity grade? (Grade III (severe) = ≥1 organ dysfunction (circulatory needing vasopressors, neurological, respiratory P/F <300, renal, hepatic INR >1.5, hematologic PLT <100k). Grade II (moderate) = ≥2 of: WBC >12 or <4, temperature ≥39°C, age ≥75, T-bil ≥5, hypoalbuminemia. Grade I (mild) = not meeting II/III.)
   • Grade I (mild) → Grade I (mild)
   • Grade II (moderate) → Grade II (moderate)
   • Grade III (severe) → Grade III (severe)
4. [End] Grade I (mild)
   Broad-spectrum antibiotics (cover gram-negative enteric organisms) + support; send blood/bile cultures. Most respond to initial treatment; if no response within 24 h, perform biliary drainage (ERCP/percutaneous). The cause (stones, etc.) and cholecystectomy are managed after the acute episode resolves.
5. [End] Grade II (moderate)
   Broad-spectrum antibiotics + support + early (within 48 h) biliary drainage (endoscopic or percutaneous transhepatic) to relieve obstruction; send blood/bile cultures. Drainage is key — do not rely on antibiotics alone.
6. [End] Grade III (severe)
   Sepsis bundle and organ support (ICU, vasopressors, mechanical ventilation if needed); urgent biliary drainage as soon as hemodynamically stable. Antibiotics: within 1 h for septic shock, within 4–6 h if not in shock.

Source guidelines & references

• Tokyo Guidelines 2018 (TG18): diagnosis, grading and management of acute cholangitis. J Hepatobiliary Pancreat Sci 2018

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways