Ascending cholangitis is a bacterial infection (typically E. coli) of the biliary tree. The most common predisposing factor is gallstones.

PC

Charcot's triad of right upper quadrant (RUQ) pain, fever and jaundice occurs in about 20-50% of patients

• fever is the most common feature, seen in 90% of patients
• RUQ pain 70%
• jaundice 60% (If no jaundice, look for obstructive picture in LFTs)
• hypotension and confusion are also common (the additional 2 factors in addition to the 3 above make Reynolds' pentad)

Investigations

Labs:

• raised inflammatory markers
• LFT - obstructive picture
• blood cultures

Imaging:

• CXR - may be done to rule out perf
• ultrasound is generally used first-line in suspected cases to look for bile duct dilation (>7mm) and bile duct stones
• MRCP is a non-invasive tool which is good at evaluating the biliary tree. It is preferred to ERCP in this instance as we have not proven a ductal stone as yet, and if the stone has passed then it would be putting the patient to unnecessary risk to proceed direct to ERCP. However there can often be a delay in organising an MRCP and many clinicians would proceed with ERCP in a patient with evidence of ascending cholangitis and a dilated CBD.

Management