Cholangitis & Obstructive Jaundice

Cholangitis is a medical emergency.
Obstructive jaundice is common and can deteriorate quickly if infection develops or obstruction is not relieved.

This guide focuses on recognising severity early and knowing what to do on the ward and on-call.

What is cholangitis and obstructive jaundice?

Obstructive jaundice
Jaundice caused by blockage of bile flow (outside the liver).

Cholangitis

Infection of the biliary tree due to obstruction.

Think of it simply:

Obstruction + infection = cholangitis
And cholangitis can become septic very quickly.

How does it present?

Obstructive jaundice:

  • Yellow skin and sclera
  • Dark urine
  • Pale stools
  • Pruritus
  • Right upper quadrant discomfort
  • Weight loss (if malignancy)

Cholangitis (more severe):

Classically described by Charcot’s triad:

  • Fever
  • Jaundice
  • Right upper quadrant pain

Severe cholangitis may show Reynolds’ pentad:

  • Hypotension
  • Confusion

These patients are septic until proven otherwise.

Common causes (think practically)

Most common causes you will see on the ward:

  • Gallstones in the bile duct (choledocholithiasis)
  • Malignancy (pancreatic cancer, cholangiocarcinoma)
  • Benign strictures
  • Blocked stents
  • Post-ERCP complications

A simple rule on-call:

Painful jaundice with fever → think stones
Painless progressive jaundice → think malignancy

On the ward, always ask

Is this patient septic from a biliary source?

Because management changes immediately if the answer is yes.

First priority = assess severity and sepsis

Before thinking about scans:

Assess:

  • NEWS score
  • BP and heart rate
  • Temperature
  • Mental state
  • Lactate
  • Urine output

Cholangitis can progress rapidly to septic shock.

Immediate management on the ward (what juniors should actually do)

If you suspect cholangitis:

Do immediately:

  • A–E assessment
  • Blood cultures
  • Bloods: FBC, U&E, LFTs, INR, CRP
  • VBG/ABG and lactate if unwell
  • IV access (large bore cannulae)
  • Start IV antibiotics early (as per local guideline)
  • IV fluids if hypotensive
  • Monitor closely

Do not wait for imaging before starting antibiotics if the patient is septic.

Imaging (real-world NHS approach)

  • Ultrasound abdomen → first-line
    Looks for bile duct dilatation, stones, gallbladder pathology
  • MRCP → if ultrasound unclear but suspicion remains
  • CT → useful if malignancy suspected or diagnosis unclear

Imaging helps identify obstruction — but clinical deterioration drives urgency.

Definitive management

If obstruction is present, especially with cholangitis, the patient usually needs:

  • Urgent biliary decompression
    • ERCP
    • Stent insertion
    • Occasionally percutaneous drainage

Antibiotics alone are not enough if the duct remains blocked.

When to escalate

Escalate urgently if:

  • Fever with jaundice
  • Hypotension
  • Confusion
  • Rising bilirubin with infection
  • Lactate elevated
  • NEWS ≥5
  • Concerned nursing staff

These patients often need:

  • Gastro/hepatobiliary registrar input
  • ERCP within hours
  • HDU/ICU if unstable

Do not leave suspected cholangitis to “wait for scan tomorrow”.

Common mistakes juniors make

  • Delaying antibiotics while waiting for imaging
  • Underestimating fever + jaundice
  • Not recognising blocked stents as a cause
  • Assuming all jaundice is “liver disease”
  • Delaying escalation for ERCP

Take-home concept

Obstructive jaundice becomes dangerous when infection develops.
Your job is to recognise cholangitis early, treat sepsis immediately, and escalate for urgent biliary drainage.