Diagnosis and Management of Acute Cholangitis

Importance Acute cholangitis (AC) is a potentially fatal biliary tract infection most commonly caused by gallstones. While modern-day treatments with antibiotics and biliary decompression have drastically decreased mortality rates, AC still requires prompt intervention. Observations Diagnosis of AC traditionally relied on the presence of the Charcot triad, which has since proven to incompletely capture the complexity of this condition. Modern-day diagnosis, severity grading, and management guidelines provide a more holistic approach. Tokyo Guidelines (TG) are widely used, though newer guidelines, namely the BILE criteria, have recently emerged. These criteria include demonstration of inflammation, cholestasis, and biliary obstruction. Ultrasound is first-line imaging modality with computed tomography or magnetic resonance cholangiopancreatography often used for diagnostic dilemmas. Treatment is dependent on severity, though guidelines generally recommend early decompression (most commonly with endoscopic retrograde cholangiopancreatography [ERCP]) for moderate to severe cases. The optimal timing of biliary drainage remains unclear, with mixed evidence from observational studies and no universal definition of what constitutes “early” vs “urgent” drainage. Laparoscopic cholecystectomy should be performed during index hospitalization, when possible, with multiple studies demonstrating lower morbidity and mortality rates when compared with interval procedures. The prognosis of AC is favorable if treated swiftly and appropriately; in turn, mortality rates increase with severity and delays in diagnosis. Conclusions and Relevance AC can be challenging to diagnose and the precise timing of biliary drainage and cholecystectomy is debated. This comprehensive review reflects the most recent evidence and recommendations on severity grading, resuscitation, and timing of ERCP and cholecystectomy to assist clinicians who manage these complex patients.