Learning Objectives

By the end of this article, readers will be able to:
1. Define acute severe cholangitis and list common etiologies.
2. Explain the pathophysiology and clinical features, including Charcot’s triad and Reynolds’ pentad.
3. Apply the Tokyo Guidelines to classify disease severity.
4. Outline the stepwise management: resuscitation, antibiotics, and biliary drainage.
5. Discuss nursing roles and patient education strategies for ACST.

Introduction

Acute severe cholangitis (ACST) is a life-threatening infection of the biliary tract caused by obstruction and bacterial contamination. Early recognition and prompt intervention are vital to reduce morbidity and mortality.

Anatomy Review

• Gallbladder: stores bile produced by the liver.
• Common bile duct: carries bile from liver and gallbladder to duodenum.
• Biliary obstruction anywhere along this tract predisposes to infection.

Pathophysiology

1. Obstruction (stones, strictures, tumors, parasites) → bile stasis.
2. Bacterial overgrowth in static bile (E. coli, Klebsiella, Enterococcus).
3. Pressure increase damages duct epithelium → endotoxin and inflammatory cytokines enter circulation.
4. Systemic inflammatory response → sepsis, organ dysfunction.

Clinical Presentation

• Charcot’s Triad:
• Fever with chills
• Right upper quadrant pain
• Jaundice
• Reynolds’ Pentad (severe cholangitis): adds hypotension and altered mental status.

Case Vignette

A 72-year-old male with a history of gallstones presents with 2 days of fever, RUQ pain, and dark urine. On exam: BP 90/60 mmHg, temp 39.2°C, jaundice, RUQ tenderness. Labs show leukocytosis, elevated ALP and bilirubin.

Diagnostic Evaluation

• Labs: CBC, LFTs (cholestatic pattern), CRP, blood cultures.
• Imaging:
• Ultrasound: biliary dilation.
• MRI/MRCP or CT: detailed biliary anatomy.

Tokyo Guidelines Severity Classification

| Grade | Criteria | Management Priority |
|——-|———————————————|————————–|
| I | No organ dysfunction | Medical therapy |
| II | WBC >12k, fever ≥39°C, age ≥75, bilirubin ≥5 | Consider early drainage |
| III | Organ dysfunction (CV, neuro, renal, etc.) | Urgent biliary decompression |

Management

1. Initial Resuscitation
2. IV fluids, hemodynamic support, oxygen
3. Empiric Antibiotics
4. Broad-spectrum (e.g., piperacillin–tazobactam)
5. Biliary Drainage (within 24–48 h)
6. ERCP with sphincterotomy and stenting
7. PTBD if ERCP not feasible
8. Supportive Care
9. Monitor organ function, manage complications

Nursing Considerations

• Frequent vital signs, I/O monitoring
• Prepare and educate patient for ERCP/PTBD
• Administer antibiotics and fluids on schedule
• Post-procedure care: monitor for bleeding, infection

Self-Assessment Quiz

1. Which finding is part of Reynolds’ pentad?
   A. Elevated ALP
   B. Hypotension
   C. Right flank pain
   D. Bradycardia

2. First-line imaging for suspected ACST in a stable patient is:
   A. CT scan
   B. ERCP
   C. Ultrasound
   D. MRI

Summary

ACST requires rapid identification of the classic triad and pentad, aggressive resuscitation, targeted antibiotics, and timely biliary decompression to improve outcomes. Multidisciplinary care, including vigilant nursing support and patient education, is essential.

References

1. Kiriyama S, Takada T, et al. TG18 guidelines: diagnosis and severity grading of acute cholangitis. J Hepatobiliary Pancreat Sci. 2018;25(1):17–30.
2. Sartelli M, Catena F, et al. WSES guidelines for acute cholangitis. World J Emerg Surg. 2017;12:31.
3. Solomkin JS, Mazuski JE, et al. SIS/IDSA guidelines for IAI. Clin Infect Dis. 2010;50(2):133–164.