Gastrointestinal & Hepatic · Topic 12 of 26

Cholecystitis & Acute Cholangitis

Gastrointestinal · biliary tract

Cholecystitis & Acute Cholangitis

Inflamed gallbladder: early laparoscopic cholecystectomy. Infected bile duct (fever, pain, jaundice): antibiotics plus biliary drainage timed by Tokyo grade.

Key numbers

Tokyo cholangitis: inflammation, cholestasis, imagingbilirubin ≥ 2 mg/dL

Drain the bile duct, timed by gradegrade II: drain ≤ 48 h

Early laparoscopic cholecystectomy for acute cholecystitis≤ 7 d of admission

Dilated common bile duct over 6 mmCBD > 6 mm

01 · Look forCharcot triad: fever, RUQ pain, jaundice

Cholangitis classically gives Charcot triad — fever or chills, right upper quadrant pain and jaundice — specific but present in only a minority; Reynolds pentad adds hypotension and confusion, signalling septic shock.

02 · DoDrain the bile duct, timed by grade

Biliary drainage (ERCP first, or percutaneous transhepatic) is definitive: grade III as soon as the patient is stabilized, grade II within 48 hours, grade I if antibiotics fail to work within 24 hours.

03 · DoEarly laparoscopic cholecystectomy for acute cholecystitis

Treat acute cholecystitis with early laparoscopic cholecystectomy — within 7 days of admission and 10 days of symptom onset, ideally within 24–48 hours if fit; percutaneous cholecystostomy suits very high surgical risk.

Diagnosis & monitoring

Work-up

Tokyo cholangitis: inflammation, cholestasis, imaging must knowTG18 definite cholangitis needs one of each: inflammation (fever > 38 °C, abnormal WBC, raised CRP), cholestasis (bilirubin ≥ 2 mg/dL or liver enzymes > 1.5× ULN) and imaging (duct dilation, stone, stricture or stent).

Tokyo cholecystitis: local, systemic and imaging signsTG18 definite acute cholecystitis = a local sign (Murphy sign or right upper quadrant mass, pain or tenderness) plus a systemic sign (fever, raised CRP or WBC) plus characteristic imaging.

Moderate cholecystitis: WBC over 18,000 or 72 hoursTG18 grade II (moderate) cholecystitis has any of: WBC > 18,000/mm³, a palpable tender RUQ mass, symptoms > 72 hours, or marked local inflammation (gangrene, abscess, emphysematous cholecystitis); grade III adds organ dysfunction.

Grade III = any organ dysfunctionTG18 grade III (severe) cholangitis or cholecystitis = organ dysfunction: vasopressor need, altered consciousness, PaO2/FiO2 < 300, oliguria or creatinine > 2.0 mg/dL, INR > 1.5, or platelets < 100,000/mm³.

Dilated common bile duct over 6 mmThe common bile duct is dilated above 6 mm with the gallbladder in place (above 10 mm after cholecystectomy); MRCP is highly accurate for retained stones, and ERCP is reserved for when treatment is needed.

Do right now

In this order

First moves

Blood cultures, then broad gram-negative antibiotics

→

Grade III = any organ dysfunction

→

Drain the bile duct, timed by gradegrade II: drain ≤ 48 h

Why each step

Blood cultures, then broad gram-negative antibioticsDraw blood cultures and start IV antibiotics covering gram-negative enteric organisms — piperacillin–tazobactam, a third-generation cephalosporin, or meropenem in the very ill — with fluids and analgesia.

Drain the bile duct, timed by gradeBiliary drainage (ERCP first, or percutaneous transhepatic) is definitive: grade III as soon as the patient is stabilized, grade II within 48 hours, grade I if antibiotics fail to work within 24 hours.

Management

Orders

Ultrasound first; HIDA scan if equivocalOrder right upper quadrant ultrasound first (stones, wall thickening, pericholecystic fluid, sonographic Murphy sign); if equivocal, cholescintigraphy (HIDA) showing a non-filling gallbladder confirms cystic duct obstruction.

Cholangitis antibiotics 4–7 days after drainageAfter successful biliary drainage, TG18 gives 4–7 days of antibiotics, extended to 2 weeks for enterococcal or streptococcal bacteremia; after cholecystectomy for mild–moderate cholecystitis, antibiotics can stop within 24 hours.

ERCP with sphincterotomy clears duct stonesERCP with sphincterotomy and stone extraction treats choledocholithiasis (success > 95%); for gallstones, cholecystectomy follows once the cholangitis resolves, and gallstone pancreatitis with cholangitis needs ERCP within 24 hours.

Red flags & don'ts

Avoid harm

Acalculous cholecystitis in the critically ill complicationAcalculous cholecystitis (5–10% of cases) strikes after major surgery, burns, sepsis, trauma, prolonged fasting or parenteral nutrition; unexplained fever may be the only clue, it progresses quickly to gangrene, and percutaneous cholecystostomy is common treatment.

Worsening pain and rigors: gangrene or perforation complicationIncreasing pain, high fever, rigors, rebound tenderness or ileus suggest gallbladder empyema, gangrene or perforation (about 10% untreated, mortality up to 16%) — these need urgent cholecystectomy.

Cholecystitis or cholangitis?

Commonly confused

Problem	Stone impacted in the cystic duct; gallbladder inflamed
Classic finding	Murphy sign, RUQ pain over 6 hours
Bilirubin	Normal or mildly raised (up to 4 mg/dL)
Source control	Early laparoscopic cholecystectomy
High-risk patient	Percutaneous cholecystostomy

More detail

Reference

Show 7 reference facts

TG18 grade II (moderate) cholangitis = any two of WBC > 12,000 or < 4,000, fever ≥ 39 °C, age ≥ 75, bilirubin ≥ 5 mg/dL, or hypoalbuminemia.

In uncomplicated cholecystitis, liver tests are normal or mildly raised (bilirubin up to 4 mg/dL); higher values or lipase above 3× normal suggest a duct stone or gallstone pancreatitis.

About 85% of cholangitis comes from common duct stones; strictures, tumors and blocked stents cause the rest. Usual organisms are E. coli, Klebsiella and Enterobacter, then Enterococcus and anaerobes.

TG18 high surgical risk — Charlson index ≥ 6 or ASA ≥ 3 in grade I–II, CCI ≥ 4 and ASA ≥ 3 in grade III — favors antibiotics or gallbladder drainage, then delayed cholecystectomy.

Older adults may present with only anorexia, vomiting, malaise or weakness, sometimes without fever.

Mirizzi syndrome is a cystic duct stone compressing the common duct and causing jaundice; a cholecystoenteric fistula can let a large stone obstruct the small bowel (gallstone ileus).

When surgery is deferred for comorbidity and cholecystitis settles, cholecystectomy can follow 6 weeks or more later, accepting a risk of recurrent biliary events.

Pearl

Cholecystitis: take the gallbladder out. Cholangitis: drain the duct — antibiotics alone do not fix an obstructed, infected system.

Sources · Merck Manual Professional — Acute Cholecystitis · Merck Manual Professional — Choledocholithiasis and Cholangitis · Kiriyama S et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis. J Hepatobiliary Pancreat Sci 2018;25:17–30 · Yokoe M et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci 2018;25:41–54 · MDCalc — Tokyo Guidelines for Acute Cholangitis 2018 (criteria and management by grade) · MDCalc — Tokyo Guidelines for Acute Cholecystitis 2018 (criteria and management by grade) · Early Management of Severe Biliary Infection in the Era of the Tokyo Guidelines. J Clin Med 2023;12:4711 (reproduces TG18/TG13 criteria and grading tables) · Navigating antibiotic therapy in acute cholangitis: Best practices and new insights. J Hepatobiliary Pancreat Sci 2025 · The Hospitalist (SHM), June 2026 — Applying the 2024 ACG Guidelines on Acute Pancreatitis to Hospital Medicine · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).