CBD stone on ultrasound or cross-sectional imaging
Clinical ascending cholangitis
Very high bilirubin with dilated CBD context
Intermediate probability features
Abnormal liver tests
Age risk
Dilated CBD without visible stone
Low probability features
No predictors
Normal liver tests
MRI
MRCP and biliary MRI role
Indications
Intermediate probability choledocholithiasis
Inconclusive ultrasound
Suspected malignancy or stricture mapping
Advantages
Noninvasive duct visualization
No ionizing radiation
Limitations
Availability and timing in sepsis
Motion artifact with pain
Contraindications with noncompatible implants
Interpretation pearls
Stone signal voids
Duct caliber transition point suggesting obstruction
CT
CT abdomen role
Indications
Alternative diagnosis evaluation
Complication evaluation
Malignancy suspicion
Strengths
Pancreatitis complications
Perforation or abscess
Mass lesions
Weaknesses for CBD stones
Radiolucent stones missed
Lower sensitivity than MRCP or EUS
Imaging targets
Biliary dilation
Pneumobilia
Periportal edema
Gallbladder inflammation overlap
Ultrasound (or US)
RUQ ultrasound first-line imaging
Key findings
CBD dilation
Intrahepatic duct dilation
Gallstones
Sonographic Murphy sign
Interpretation pearls
CBD diameter increases with age
Post-cholecystectomy CBD can be larger baseline
Limitations
Distal CBD visualization difficulty
Stone absence does not exclude choledocholithiasis
POCUS considerations
Rapid bile duct and gallbladder assessment
Hemodynamic ultrasound adjunct in shock
Disposition
Level of care and timing
Disposition framework
Grade III cholangitis
ICU admission
Emergent biliary decompression pathway
Grade II cholangitis
Monitored bed or step-down
Urgent ERCP planning within 24 hours when feasible
Grade I cholangitis
Inpatient admission for IV antibiotics
Early GI consultation for definitive stone management
Choledocholithiasis without cholangitis
Admission for ongoing obstruction
Discharge only with low-risk profile and reliable follow-up
Consultation and transfer triggers
Definitive care coordination
Gastroenterology consultation
ERCP planning
EUS or MRCP selection for intermediate risk
Surgery consultation
Cholecystectomy planning after duct clearance
Cholecystitis overlap management
Interventional radiology consultation
Percutaneous transhepatic biliary drainage when ERCP unavailable or failed
Cholecystostomy for severe cholecystitis overlap
Transfer criteria
No ERCP capability
Hemodynamic instability requiring ICU and urgent decompression
Need for hepatobiliary surgery
Treatment
Resuscitation and supportive care
Supportive care bundle
Fluids
Balanced crystalloid boluses
Reassessment after each bolus
Pulmonary edema monitoring in heart failure
Vasopressors
Initiate norepinephrine for persistent hypotension after fluids
Starting dose 0.05 to 0.1 mcg/kg/min
Titrate every 2 to 5 minutes to MAP target
Add vasopressin for escalating norepinephrine requirement
Fixed dose 0.03 units/min
Avoid titration above standard septic shock dosing
Oxygenation
Supplemental oxygen to SpO2 target per baseline status
Intubation for refractory hypoxemia or airway protection
Antibiotics
Empiric antibiotics for cholangitis
Timing principles
Septic shock physiology
Initiate within 1 hour of recognition
Blood cultures first when feasible
Nonshock cholangitis
Initiate early after cultures
De-escalation after susceptibilities
Community-acquired without high ESBL risk
Piperacillin-tazobactam IV
4.5 g every 6 hours
Renal dose adjustment
Ceftriaxone IV plus metronidazole IV
Ceftriaxone 2 g every 24 hours
Metronidazole 500 mg every 8 hours
Severe sepsis or healthcare-associated or ESBL risk
Meropenem IV
1 g every 8 hours
Renal dose adjustment
Imipenem-cilastatin IV
500 mg every 6 hours
Renal dose adjustment
Enterococcus coverage contexts
Prior biliary instrumentation
Biliary stent
Prior ERCP
Immunocompromised host
Neutropenia
Transplant
Ampicillin-sulbactam alternative where susceptible patterns support
3 g every 6 hours
Avoid if high resistance prevalence locally
MRSA coverage contexts
Indwelling catheters with suspected MRSA source
Add vancomycin IV
Trough or AUC-based dosing per local protocol
Duration guidance after source control
Uncomplicated after successful biliary drainage
4 to 7 days total typical
Shorter course when rapid clinical response and cultures guide
Persistent obstruction or bacteremia
Extended duration individualized
Infectious diseases consultation when uncertain
Biliary decompression and definitive management
Source control pathways
ERCP preferred decompression
Indications
Definite cholangitis with obstruction evidence
Severe cholangitis Grade III
Worsening labs or physiology despite antibiotics
Interventions
Sphincterotomy
Stone extraction
Biliary stent placement
Nasobiliary drainage option
Timing targets
Grade III severe
Emergent decompression as soon as feasible
Consider within 12 hours when available
Grade II moderate
Urgent decompression within 24 hours when feasible
Grade I mild
Early decompression during admission
Select cases after stabilization
Percutaneous transhepatic biliary drainage
Indications
ERCP unavailable
Failed ERCP
Altered anatomy limiting ERCP access
Risks
Bleeding
Bile leak
Catheter dislodgement
Surgical decompression
Indications
Failed endoscopic and percutaneous options
Concomitant surgical abdomen
Higher morbidity context
Reserve for refractory scenarios
Hepatobiliary surgery involvement
Stone prevention and interval care
Post-decompression planning
Cholecystectomy after duct clearance
Same-admission strategy when stable
Reduced recurrence risk compared with delayed surgery
If not surgical candidate
Biliary stent strategy with scheduled exchange
Recurrent cholangitis prevention planning
Evidence label standardization for this reference
Evidence labels used for bedside prioritization
Class I internal label
Strong guideline-consistent practice
Early antibiotics in cholangitis with sepsis physiology
Urgent biliary decompression in severe cholangitis
Class IIa internal label
Reasonable practice supported by guideline consensus
MRCP or EUS for intermediate choledocholithiasis probability
Class IIb internal label
Selective practice based on context
Vancomycin addition without clear MRSA risk
ACEP Level C internal label
Consensus-based ED process standardization
Early GI activation for suspected cholangitis
Special Populations
Pregnancy
Pregnancy considerations
Diagnostic imaging selection
Ultrasound first-line
MRCP preferred over CT when feasible
Antibiotic selection safety
Beta-lactams generally compatible
Avoid tetracyclines
Avoid fluoroquinolones when alternatives exist
Procedural considerations
ERCP in pregnancy when necessary for cholangitis
Minimize fluoroscopy time
Obstetric coordination
Maternal stabilization priority
Fetal monitoring in viable gestation when resources allow
Geriatric
Older adult considerations
Atypical presentation risk
Fever absent
Delirium predominant
Baseline biliary dilation confounder
Larger CBD with age
Interpret with symptoms and labs
Medication risk
Renal dosing adjustments
Higher delirium risk with opioids and anticholinergics
Disposition bias toward admission
Higher decompensation risk
Lower physiologic reserve
Pediatrics
Pediatric considerations
Etiology differences
Hemolytic disease pigment stones
Congenital biliary anomalies
Imaging strategy
Ultrasound first-line
MRCP for unclear cases
Antibiotic dosing weight-based
Local pediatric protocols
Renal and hepatic adjustment
Specialist involvement
Pediatric gastroenterology
Pediatric surgery when indicated
Background
Epidemiology
Epidemiology and burden
Gallstones common in adult populations
Risk increases with age
Higher prevalence in females
Choledocholithiasis subset
CBD stones can occur with or without cholecystitis
Retained stones possible after cholecystectomy
Cholangitis as a time-critical infection
Mortality increases with delayed drainage
Severe disease more frequent in elderly and comorbid patients
Pathophysiology
Mechanisms
Biliary obstruction
Increased intraductal pressure
Impaired bile flow and clearance
Bacterial ascent and translocation
Duodenal flora access to biliary tree
Bacteremia with rigors
Systemic inflammatory response
Sepsis physiology
End-organ dysfunction in severe cases
Stone behavior
Intermittent obstruction with transient LFT spikes
Persistent obstruction with progressive cholestasis
Therapeutic Considerations
Rationale for combined therapy
Antibiotics alone insufficient with persistent obstruction
Limited penetration and persistent nidus
Higher recurrence without drainage
Early drainage improves outcomes
Rapid source control
Shorter antibiotic courses after decompression
Imaging selection aligned to risk
High probability
Direct ERCP pathway
Intermediate probability
MRCP or EUS to confirm
Low probability
Avoid ERCP risks
Patient Discharge Instructions
copy discharge instructions
Discharge criteria dependent counseling
Typical discharge uncommon for cholangitis
Admission expectation with suspected cholangitis
Discharge only after clear alternative diagnosis and stability
If discharged after low-risk suspected stone passage
Oral hydration
Low-fat diet until reassessed
Return to ED immediately for red flags
Fever or rigors
Temperature >= 38.0 C
Shaking chills
Worsening jaundice
Increasing yellowing of eyes or skin
Dark urine or pale stools worsening
Persistent or worsening abdominal pain
RUQ or epigastric pain not improving
New generalized abdominal pain
Vomiting with inability to keep fluids down
Signs of dehydration
Dizziness or fainting
Confusion or severe weakness
New trouble staying awake
New trouble thinking clearly
Low urine output
Markedly reduced urination
New swelling or shortness of breath
Follow-up plan
Urgent follow-up within 24 to 72 hours if discharged
Repeat liver tests if symptoms persist
Imaging review plan
Post-ERCP follow-up if treated inpatient
Cholecystectomy planning
Stent exchange scheduling if stent placed
References
Clinical guidelines and consensus sources
Key guideline sources
Tokyo Guidelines for acute cholangitis and cholecystitis
Diagnostic criteria and severity grading
Drainage timing principles by severity
ASGE guidance on choledocholithiasis risk stratification
High probability ERCP pathway
Intermediate probability MRCP or EUS pathway
Surviving Sepsis Campaign principles for sepsis management
Early antibiotics and resuscitation targets
Vasopressor MAP target framework
Coding systems and internal specification
Standardization references
ICD-10 choledocholithiasis K80.5
ICD-10 cholangitis K83.0
SNOMED CT ascending cholangitis concept mapping
Internal formatting specification
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