Acute cholangitis and gallstone pancreatitis
Two emergencies caused by a stone in the duct. One needs drainage now; the other usually needs patience, then a cholecystectomy before the patient goes home.
Reviewed against its sources on 25 October 2026.
- Diagnose and grade cholangitis with Tokyo 2018: antibiotics for all, drainage by grade.
- Gallstone pancreatitis without cholangitis needs neither urgent ERCP (APEC) nor prophylactic antibiotics.
- After mild gallstone pancreatitis, remove the gallbladder in the same admission (PONCHO).
01Acute cholangitis: making the diagnosis
- Cholangitis is infection in an obstructed bile duct. In gallstone disease the cause is a stone in the common duct.
- Use the Tokyo 2018 criteria. They are the 2013 criteria, kept unchanged in 2018, and they diagnose more cases than the 2007 version did.
- The treatment is antibiotics and drainage of the duct. Cholecystectomy comes later.
| Group | Criteria (Tokyo 2018) |
|---|---|
| A Systemic inflammation | Fever above 38 °C and/or shaking chills; or laboratory evidence of inflammation: white cells below 4,000 or above 10,000/mm³, or CRP 1 mg/dL or more |
| B Cholestasis | Bilirubin 2 mg/dL or more; or ALP, GGT, AST or ALT above 1.5 times the upper limit of normal |
| C Imaging | A dilated duct, or evidence of the cause: stone, stricture, stent |
Suspected: one item from A plus one from B or C. Definite: one item from each of A, B and C.
Source
Kiriyama et al., J Hepatobiliary Pancreat Sci 2018;25:17-30: the guideline group recommended that the 2013 criteria “be adopted in the TG18 guidelines and used as standard practice”. They were validated in a large case series, which found a higher diagnostic rate than the 2007 criteria and higher 30-day mortality with higher grade. Guideline
02Grading severity
| Grade | Criteria (Tokyo 2018) | Drainage |
|---|---|---|
| III severe | Any one organ dysfunction: hypotension needing dopamine 5 µg/kg/min or more, or any noradrenaline; disturbed consciousness; PaO₂/FiO₂ below 300; oliguria or creatinine above 2.0 mg/dL; INR above 1.5; platelets below 100,000/mm³ | Urgent, as soon as organ support makes it safe |
| II moderate | Any two of: white cells above 12,000 or below 4,000/mm³; fever 39 °C or more; age 75 or over; bilirubin 5 mg/dL or more; albumin below 0.7 times the lower limit of normal | Early |
| I mild | Neither grade II nor grade III at diagnosis | If no response to antibiotics within 24 hours |
Grade at diagnosis and grade again if the patient worsens. A grade I patient who is not better the next morning is treated as grade II. Expert opinion
Sources
Severity criteria: Kiriyama et al., 2018, adopting the 2013 grading unchanged; in the validation series early or urgent drainage was associated with lower 30-day mortality in grade II patients. Management by grade: Miura et al., J Hepatobiliary Pancreat Sci 2018;25:31-40 (the TG18 flowchart). Guideline
03Treating cholangitis
- Resuscitate and take cultures. Blood cultures before antibiotics; bile for culture at drainage.
- Antibiotics now. Follow the local protocol, chosen by severity and by whether the infection was caught in the community or in hospital (the Tokyo 2018 antimicrobial table).
- Drain the duct by grade. Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction or a stent is first choice. Percutaneous drainage if ERCP fails or is not possible (surgically altered anatomy, an unstable patient in a unit without endoscopy). Open drainage is a last resort.
- Stop the antibiotics on time. Tokyo 2018 recommends 4 to 7 days once the source is controlled. A Dutch trial presented in 2026 found one day non-inferior after good drainage.
- Then deal with the gallbladder. Plan cholecystectomy once the cholangitis has settled, ideally in the same admission. Expert opinion
- Treat septic shock as grade III and get the endoscopist in early.
- Use a stent and come back later if the patient is too sick for a full clearance.
- Check that the duct is clear before cholecystectomy, or plan to clear it at the operation.
- Wait for a magnetic resonance cholangiopancreatography (MRCP) in a septic patient with a dilated duct. Drain first.
- Operate on the gallbladder in a patient with untreated cholangitis.
- Run antibiotics for weeks after successful drainage.
Sources
Flowchart and drainage: Miura et al., 2018. Antibiotic choice and duration: Gomi et al., Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. Guideline One day versus 4 to 7 days: COBRA trial, presented at Digestive Disease Week, May 2026 (reported in HCPLive; protocol Overdevest et al., Trials 2026). Patients had distal obstruction, adequate endoscopic drainage and no fever within 24 hours of ERCP. Absolute difference 1.5 percent, one-sided 95% confidence limit −2.4 percent against a margin of −7.5 percent. Not yet published in full. Contested
04Gallstone pancreatitis: diagnosis and severity
- Diagnose acute pancreatitis on two of three: typical upper abdominal pain, lipase or amylase at least three times the upper limit of normal, and typical imaging (revised Atlanta classification, 2012).
- Severity is decided by organ failure and its duration, not by the enzyme level.
- Call it gallstone pancreatitis when there are gallstones or sludge and no other cause. A raised ALT early on supports it. Expert opinion
| Grade (revised Atlanta) | Definition |
|---|---|
| Mild | No organ failure, no local or systemic complications. The commonest; usually settles within a week. |
| Moderately severe | Transient organ failure (settles within 48 hours), and/or local complications, and/or a flare of a co-morbid disease |
| Severe | Persistent organ failure: more than 48 hours |
Organ failure
Respiratory, cardiovascular or renal failure, scored with the modified Marshall system (a score of 2 or more in one system).
Local complications
Under 4 weeks: acute peripancreatic fluid collection, acute necrotic collection. After 4 weeks, once walled off: pseudocyst, walled-off necrosis. Any of them can be sterile or infected.
Source
Banks et al., Gut 2013;62:102-111: Classification of acute pancreatitis 2012, revision of the Atlanta classification by international consensus. “Severe acute pancreatitis is defined by persistent organ failure, that is, organ failure >48 h.” Consensus
05ERCP and antibiotics in pancreatitis
- With cholangitis: ERCP early, as for any cholangitis.
- Without cholangitis: no urgent ERCP, even in predicted severe disease. The APEC trial found no benefit.
- Ongoing obstruction (bilirubin rising, a stone seen in the duct): ERCP. If you are not sure there is still a stone, MRCP or endoscopic ultrasound first.
Sources
Schepers et al., Lancet 2020;396:167-176 (APEC): predicted severe gallstone pancreatitis without cholangitis; urgent ERCP with sphincterotomy within 24 hours versus conservative treatment with ERCP only for cholangitis or persistent cholestasis. 38 versus 44 percent, p = 0.37. Randomised trial Tenner et al., ACG guideline, Am J Gastroenterol 2024;119:419-437: medical therapy over early ERCP in biliary pancreatitis without cholangitis (conditional, low quality); against prophylactic antibiotics in severe pancreatitis (conditional, very low quality); MRCP or endoscopic ultrasound rather than diagnostic ERCP. Guideline
06When the gallbladder comes out
- Mild gallstone pancreatitis: in the same admission. Waiting a month more than triples the readmissions for another gallstone event.
- Severe pancreatitis with collections or necrosis: wait until the collections have resolved or matured, and plan with the pancreatic team. Expert opinion
- Not fit for surgery: an ERCP sphincterotomy reduces the risk of another attack. Expert opinion
- Book the cholecystectomy as soon as the pain has settled and the patient is eating. Expert opinion
- Check the duct at operation or before it if the liver tests have not settled.
- Discharge a patient after mild pancreatitis with only a routine waiting-list slip.
- Operate early in the presence of acute collections or necrosis.
Sources
da Costa et al., Lancet 2015;386:1261-1268 (PONCHO): 6 of 128 versus 23 of 136 patients; one bile leak and one bleed after surgery in each group. Randomised trial UK guidance: UK working party guideline, Gut 2005, which asks for definitive management of the gallstones in the same admission “unless a clear plan has been made for definitive treatment within the next two weeks”. NICE covers gallstone treatment after pancreatitis in NG104 (2018). ACG 2024: patients with mild biliary pancreatitis should have cholecystectomy early, preferably before discharge. Guideline
07What examiners ask
- Define acute cholangitis by the Tokyo criteria, and grade this patient.
- A 78-year-old has fever, a bilirubin of 5.3 mg/dL and a white count of 14,000/mm³. What grade, and how soon does she need an ERCP?
- Should every patient with gallstone pancreatitis have an ERCP? What did the APEC trial show?
- Define severe acute pancreatitis by the revised Atlanta classification.
- When would you remove the gallbladder after mild pancreatitis, and after severe pancreatitis with necrosis?
Test yourself further: Practise questions on Cholangitis and pancreatitis in the Exam zone.