Ascending Cholangitis 101

Today at Parkland Morning Report we talked about the diagnosis and management of ascending cholangitis. Below is a summary of cholangitis from last week’s Potpourri. Check it out!

  • Frequently polymicrobial from gastrointestinal flora including E. coli, Klebsiella, Enterobacter, Enterococcus, Anaerobes
  • Pathogenic role of enterococci and anaerobes is not well defined
  • Results from bacterial infection in the setting of an obstructed biliary tree
  • Sources of obstruction include gallstones, strictures, biliary or pancreatic malignancy, iatrogenic from occluded stent or drain
  • Charcot Triad: fever, jaundice, and RUQ pain (all three present in <50% of cases)
  • Reynold’s pentad: Charcot’s triad + altered mental status and hypotension and is associated with increased morbidity and mortality
  • Diagnosis often made clinically but requires imaging confirmation
    • Ultrasound: recommended first imaging technique but if normal does not rule out cholangitis
    • MRCP: increasingly utilized in suspected malignancy and diagnosis of duct stones
    • ERCP: should not be used soley for diagnostic purposes due to its risk; best utilized when likelihood of intervention is high

    Management: Early ERCP should be considered in conjunction with abx therapy

    Mild-moderate disease: Ertapenem; fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin); cephalosporins; can add Flagyl for anaerobic coverage

    Severe disease: Piperacillin/tazobacatam; cephalosporin +/- Flagyl; Imipenem or Meropenem or Doripenem

    Consider adding vancomycin for health care-associated biliary infections of any severity

Advice for Physicians in Training: 40 Tips From 40 Docs

Two for one today!


  •  Time is your most precious resource. It’s nonrenewable, and it’s important to protect it. Do not be afraid to say “no” when asked to assume new responsibilities, particularly in the early stages of your career. There is no shortage of work to be done, and senior colleagues will often turn to younger, more energetic people to do it.
  •  Do say “yes” to some requests, particularly those that present opportunities for learning or other personal betterment. You didn’t get to where you are by shirking responsibility or by avoiding challenges. Say yes and no in good measure.


David Juurlink, Advice for Physicians in Training: 40 Tips From 40 Docs, The Winnower 2:e142006.67645 (2014). DOI:10.15200/winn.142006.67645