| Feature | Acute Cholangitis | Acute Cholecystitis |
|---|---|---|
| Pathophys | Bile duct obstruction + infection โ bacteremia | Gallbladder outlet obstruction (stone in cystic duct) โ inflammation ยฑ infection |
| Classic signs | Charcot triad: fever + RUQ pain + jaundice | Murphy sign: inspiratory arrest with RUQ palpation |
| Severe | Reynolds pentad: Charcot + AMS + shock | Gangrenous, emphysematous, perforated |
| Key labs | โ bili, โ ALP/GGT, โ WBC, + blood cultures | โ WBC, ยฑ mild LFT elevation |
| Imaging | CBD dilation > 8 mm, ยฑ stone visible | GB wall thickening, pericholecystic fluid, + Murphy on US |
| Treatment | ERCP within 24โ48h (emergent if septic) | Cholecystectomy within 72h |
| Grade | Severity | Criteria | Management |
|---|---|---|---|
| Grade I | Mild | Does not meet Grade II or III criteria. Responds to initial antibiotics/fluids | Antibiotics + elective/semi-urgent biliary drainage |
| Grade II | Moderate | Any 2 of: WBC >12k or <4k, fever ≥39°C, age ≥75, total bili ≥5, albumin <2.5 | Antibiotics + urgent ERCP within 24-48h |
| Grade III | Severe | Organ dysfunction in ≥1: cardiovascular (vasopressors), neurologic (AMS), respiratory (P/F <300), renal (Cr >2.0), hepatic (INR >1.5), hematologic (plt <100k) | Emergent ERCP <12-24h + ICU + organ support |
| Grade | Severity | Criteria | Management |
|---|---|---|---|
| Grade I | Mild | Healthy patient, no organ dysfunction, mild GB inflammation | Early laparoscopic cholecystectomy PONCHO, 2015 |
| Grade II | Moderate | Any of: WBC >18k, palpable RUQ mass, duration >72h, gangrenous/emphysematous GB, pericholecystic abscess | Early chole by experienced surgeon or percutaneous drainage if high risk |
| Grade III | Severe | Organ dysfunction (cardiovascular, neurologic, respiratory, renal, hepatic, hematologic) | Percutaneous cholecystostomy (bridge) → interval cholecystectomy |
| Feature | MRCP | ERCP |
|---|---|---|
| Purpose | Diagnostic, non-invasive biliary imaging | Diagnostic + therapeutic, stone extraction, stent, sphincterotomy |
| Sensitivity (CBD stones) | 85-92% | 95-98% (gold standard) |
| When to use | Intermediate probability of CBD stone (equivocal US, mild LFT elevation) | High probability CBD stone, confirmed cholangitis, therapeutic intent |
| Risks | None (non-invasive) | Post-ERCP pancreatitis (5-10%), bleeding, perforation Elmunzer et al., 2012 |
| Key rule | Use to avoid unnecessary ERCP | Use when you plan to intervene |
| TG18 Grade | Drainage Timing | Method | Key Considerations |
|---|---|---|---|
| Grade I | Elective (within days) | ERCP preferred | Stabilize with antibiotics first. Schedule ERCP during working hours |
| Grade II | Urgent (24-48h) | ERCP preferred | Start antibiotics immediately. If not responding in 24h, escalate to emergent |
| Grade III | Emergent (<12-24h) | ERCP. If fails: PTC or surgical drainage | ICU admission. Vasopressors + antibiotics + urgent GI consult |
| Severity | First-Line | Alternative | Duration |
|---|---|---|---|
| Mild-Moderate (Grade I-II) | Piperacillin-Tazobactam 4.5g IV q6h | Ceftriaxone 2g IV daily + Metronidazole 500mg IV q8h | 4-7 days after source control Van Lent et al., 2019 |
| Severe (Grade III) | Meropenem 1g IV q8h | Imipenem-Cilastatin 500mg IV q6h | 7-14 days; de-escalate based on cultures |
| PCN allergy | Ciprofloxacin 400mg IV q12h + Metronidazole 500mg IV q8h | Aztreonam 2g IV q8h + Metronidazole 500mg IV q8h | Based on severity |
| Healthcare-associated | Meropenem 1g IV q8h ± Vancomycin (if MRSA risk) | Add antifungal if prior biliary stent/prolonged antibiotics | Tailor to cultures |
| Drug | Dose | Indication |
|---|---|---|
| Piperacillin-Tazobactam (Zosyn) | 3.375โ4.5 g IV q6h | First-line for cholangitis and complicated cholecystitis SIS/IDSA, 2010 |
| Ciprofloxacin (Cipro) + Metronidazole (Flagyl) | 400 mg IV q12h + 500 mg IV q8h | Alternative if PCN allergy |
| Meropenem (Merrem) | 1g IV q8h | Severe/healthcare-associated cholangitis |
| Ketorolac (Toradol) | 15โ30 mg IV q6h | Pain -preferred over opioids initially |
Patient: 72F presents with 2 days of RUQ pain, fevers to 39.5°C, and jaundice. PMH: cholelithiasis (declined prior cholecystectomy). BP 82/54, HR 118, T 39.8°C, confused and somnolent.
Labs: WBC 22k, total bili 8.2, direct bili 6.1, ALP 580, AST 245, ALT 198, lactate 4.8, Cr 2.1 (baseline 0.9). Blood cultures drawn x2.
Imaging: RUQ US: CBD dilated to 12 mm with shadowing stone in distal CBD. Multiple gallstones in GB.
Assessment: Reynolds pentad (fever + RUQ pain + jaundice + AMS + shock) = TG18 Grade III cholangitis with organ dysfunction (cardiovascular, neurologic, renal).
Management:
Key lesson: Reynolds pentad = TG18 Grade III = emergent ERCP. Do not delay drainage for imaging. Start broad-spectrum antibiotics (meropenem for Grade III) and resuscitate aggressively. Same-admission cholecystectomy once stabilized.
Patient: 45M presents with 18 hours of progressively worsening RUQ pain radiating to right scapula, nausea, and one episode of vomiting. No fever initially. Positive Murphy sign on exam. PMH: obesity, no prior biliary disease.
Labs: WBC 14.5k, total bili 1.8 (mildly elevated), ALP 145, AST/ALT mildly elevated, lipase normal.
Imaging: RUQ US: multiple gallstones, GB wall thickening to 5 mm, pericholecystic fluid, sonographic Murphy sign positive. CBD 5 mm (normal).
Assessment: TG18 Grade I acute calculous cholecystitis (healthy patient, no organ dysfunction).
Management:
Key lesson: ACDC Trial, Ann Surg 2013 showed early cholecystectomy (within 72h) is preferred over delayed surgery. Normal CBD on US + mildly elevated bili = low risk for CBD stones, so intraoperative cholangiogram is sufficient without MRCP.
Patient: 58F presents with intermittent RUQ pain x3 days, now with dark urine and pale stools. No fever. Vitals stable. RUQ tender but no Murphy sign.
Labs: WBC 9.8k (normal), total bili 3.8, direct bili 2.9, ALP 420, GGT 380, AST 180, ALT 210. Normal lipase.
Imaging: RUQ US: gallstones present, CBD dilated to 9 mm, no definite stone visualized in CBD. No GB wall thickening or pericholecystic fluid.
Assessment: Choledocholithiasis (obstructive pattern LFTs + dilated CBD). No cholangitis (afebrile, normal WBC). No cholecystitis (no Murphy sign, no GB wall changes).
Risk stratification (ASGE):
Management:
Key lesson: Use ASGE risk stratification: high risk → ERCP directly. Intermediate risk → MRCP or EUS first. Low risk → proceed to cholecystectomy with intraoperative cholangiogram. Always give rectal indomethacin for post-ERCP pancreatitis prophylaxis.