Choledocholithiasis and cholangitisMANAGEMENT

GASTROINTESTINAL PRESENTATIONS · 12 SECTIONS

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615 items

☷ Legend

01Approach to the Critical Patient/attcp61

Immediate priorities

›High-risk biliary obstruction and infection syndromes

›Ascending cholangitis with sepsis physiology

›Hypotension

›Altered mental status

›Lactate elevation

›Obstructive jaundice with impending cholangitis

›Fever absent early

›Rising bilirubin over hours to days

›Concurrent pancreatitis concern

›Epigastric pain radiating to back

›Lipase elevation

›Immediate escalation triggers

›Systolic blood pressure < 90 mmHg after fluids

›Vasopressor requirement

›Respiratory failure

›Oliguria

›INR elevation with bleeding concern

›Total bilirubin rapidly rising

Monitoring and access

›Resuscitation setup

›Cardiac monitoring

›Continuous telemetry

›Frequent blood pressure cycling

›IV access

›Two large-bore peripheral IVs

›Intraosseous access if failed peripheral access

›Urine output monitoring

›Foley for shock or severe sepsis

›Target urine output >= 0.5 mL/kg/hour

›Respiratory monitoring

›Pulse oximetry

›End-tidal CO2 if intubated

›Arterial line indications

›Vasopressor infusion

›Frequent titration needs

Hemodynamic targets and sepsis bundle alignment

›Perfusion goals

›Mean arterial pressure >= 65 mmHg

›Norepinephrine first-line for persistent hypotension

›Vasopressin adjunct for escalating norepinephrine requirement

›Crystalloid resuscitation for hypoperfusion

›30 mL/kg within 3 hours for septic shock physiology

›Smaller boluses with frequent reassessment in heart failure

›Lactate strategy

›Initial lactate

›Repeat lactate within 2 to 4 hours if elevated

›Early source control planning

›Urgent biliary decompression pathway activation

›Gastroenterology for ERCP availability

Analgesia and antiemesis

›Symptom control framework

›Pain control compatible with hemodynamics

›Opioid titration with respiratory monitoring

›Avoid hypotension-provoking rapid boluses

›Antiemetics

›Ondansetron IV options

›Metoclopramide avoidance in bowel obstruction concern

Early antibiotics and cultures

›Sepsis antibiotics workflow

›Blood cultures before antibiotics when feasible

›Two sets from separate sites

›Do not delay antibiotics for difficult access

›Antibiotics within 1 hour for septic shock physiology

›Broad Gram-negative and anaerobe coverage

›Enterococcus coverage in high-risk contexts

02History/hx48

Presenting features and timelines

›Symptom pattern

›Fever or rigors

›Intermittent spikes suggesting bacteremia

›Recent antipyretic masking

›Right upper quadrant pain

›Colicky pain history suggesting stone migration

›Persistent pain suggesting cholecystitis overlap

›Jaundice and dark urine

›Pale stools

›Pruritus

›Nausea and vomiting

›Inability to tolerate oral intake

›Dehydration signs

›Altered mental status

›New confusion

›Somnolence

Risk factors and exposures

›Choledocholithiasis risk profile

›Prior gallstones or biliary colic

›Prior ultrasound showing cholelithiasis

›Prior cholecystectomy with retained or recurrent CBD stone

›Prior ERCP or biliary stent

›Stent occlusion timeline

›Post-ERCP complications history

›Malignancy or obstruction risk

›Pancreatic cancer concern

›Cholangiocarcinoma concern

›Primary sclerosing cholangitis

›IBD history

›Recurrent cholangitis episodes

›Parasites or travel exposures

›Liver fluke exposure risk region

›Raw freshwater fish ingestion

Severity and complication clues

›Physiologic deterioration

›Syncope or presyncope

›Hypotension episodes

›Reduced oral intake

›Dyspnea

›Sepsis-associated tachypnea

›Aspiration risk with vomiting

›Reduced urine output

›Oliguria

›Worsening baseline kidney disease

›Bleeding tendency

›Anticoagulant use

›Liver dysfunction history

›Pancreatitis features

›Epigastric pain predominance

›Prior pancreatitis

03Physical Exam/exam45

General and vitals

›Instability screen

›Temperature abnormalities

›Fever

›Hypothermia

›Tachycardia

›Atrial fibrillation trigger in sepsis

›Poor perfusion correlation

›Hypotension

›Narrow pulse pressure

›Orthostatic signs if ambulatory

›Tachypnea

›Work of breathing

›Respiratory alkalosis pattern

›Mental status

›Confusion

›Lethargy

Abdominal and hepatobiliary findings

›Abdominal exam focus

›RUQ tenderness

›Guarding

›Rebound

›Murphy sign

›Cholecystitis overlap

›Reduced reliability in elderly

›Hepatomegaly

›Congestive hepatopathy alternate

›Malignancy alternate

›Jaundice

›Scleral icterus

›Generalized skin icterus

›Peritonitis signs

›Rigid abdomen

›Pain with percussion

Sepsis and end-organ findings

›End-organ dysfunction clues

›Skin perfusion

›Mottling

›Delayed capillary refill

›Respiratory findings

›Crackles suggesting fluid overload

›Aspiration signs

›Volume status

›Dry mucous membranes

›Jugular venous distension

›Bleeding or bruising

›Coagulopathy suspicion

›Disseminated intravascular coagulation suspicion

04Differential Diagnosis/ddx39

Life-threatening mimics

›Critical alternatives

›Acute pancreatitis ICD-10 K85

›Lipase elevation

›Epigastric predominant pain

›Acute cholecystitis ICD-10 K81.0

›RUQ pain and fever

›Gallbladder wall thickening on ultrasound

›Hepatitis ICD-10 K75.9

›Marked aminotransferase elevation

›Viral exposure history

›Sepsis of non-biliary source ICD-10 A41.9

›No obstructive pattern on labs

›Alternate infection focus

›Mesenteric ischemia ICD-10 K55.9

›Pain out of proportion

›Lactate elevation without biliary obstruction evidence

Obstructive jaundice causes

›Biliary obstruction differential

›Choledocholithiasis ICD-10 K80.5

›CBD stone on imaging

›Cholestatic labs pattern

›Malignant biliary obstruction ICD-10 K83.1

›Painless jaundice

›Weight loss

›Benign biliary stricture SNOMED CT 197927001

›Prior surgery

›Chronic cholestasis pattern

›PSC ICD-10 K83.01

›IBD association

›Multifocal strictures on MRCP

›Sphincter of Oddi dysfunction ICD-10 K83.4

›Episodic biliary pain

›Post-cholecystectomy context

Hemolysis and pigment pathways

›Non-obstructive hyperbilirubinemia

›Hemolysis ICD-10 D59.9

›Elevated LDH

›Low haptoglobin

›Gilbert syndrome ICD-10 E80.4

›Isolated unconjugated bilirubin

›Triggered by fasting or illness

05Laboratory Tests/lt50

Core sepsis and biliary labs

›Essential labs set

›Complete blood count

›Leukocytosis

›Thrombocytopenia in severe sepsis

›Comprehensive metabolic panel

›Creatinine for AKI

›Electrolytes for resuscitation planning

›Liver panel

›Total bilirubin mmol/L

›Direct bilirubin mmol/L

›Alkaline phosphatase

›GGT if available

›AST

›ALT

›Lactate

›Tissue hypoperfusion marker

›Serial trend for response

›Coagulation profile

›INR

›aPTT

›Blood cultures

›Two sets

›Higher yield with rigors

Adjunct labs by presentation

›Targeted labs

›Lipase

›Gallstone pancreatitis overlap

›Alternative diagnosis support

›Venous blood gas

›pH

›pCO2 mmHg

›Bicarbonate mmol/L

›Glucose

›Stress hyperglycemia

›Hypoglycemia in severe liver dysfunction

›Type and screen

›Anticipated procedure

›GI bleeding concern

Interpretation patterns and pitfalls

›Lab pattern recognition

›Cholestatic pattern

›Disproportionate alkaline phosphatase elevation

›Bilirubin elevation

›Hepatocellular spike pattern

›AST and ALT can rise markedly with transient obstruction

›Early stone passage can mimic hepatitis

›Normal bilirubin does not exclude cholangitis

›Early disease phase

›Partial obstruction

›Leukopenia in severe sepsis

›Immunosuppression

›Poor prognostic signal

06Diagnostic Tests/dt105

Scoring Systems

›Risk and severity frameworks

›Tokyo Guidelines cholangitis diagnostic criteria

›Systemic inflammation domain

›Fever

›Elevated inflammatory markers

›Cholestasis domain

›Jaundice

›Abnormal liver tests suggesting biliary obstruction

›Imaging domain

›Biliary dilation

›Etiology evidence such as stone or stricture

›Suspected cholangitis definition

›One item from systemic inflammation

›One item from cholestasis or imaging

›Definite cholangitis definition

›One item from systemic inflammation

›One item from cholestasis

›One item from imaging

›Tokyo Guidelines severity grading

›Grade III severe

›Cardiovascular dysfunction

›Neurologic dysfunction

›Respiratory dysfunction

›Renal dysfunction

›Hepatic dysfunction

›Hematologic dysfunction

›Grade II moderate

›High fever pattern

›Leukocytosis or leukopenia thresholds

›Age risk

›Hyperbilirubinemia threshold

›Hypoalbuminemia threshold

›Grade I mild

›No Grade II or III features

›Sepsis risk tools

›qSOFA for rapid screen

›Altered mentation

›Respiratory rate >= 22

›Systolic blood pressure <= 100

›SOFA for organ dysfunction

›Respiratory component

›Coagulation component

›Liver component

›Cardiovascular component

›CNS component

›Renal component

›ASGE choledocholithiasis risk stratification

›High probability features

›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 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

07Disposition/dispo27

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

08Treatment/t115

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

09Special Populations/sp40

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

10Background/b37

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

11Patient Discharge Instructions/pdi33

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

12References/r15

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.