Acute cholangitis: HPB pathway (adult)
Suspected or confirmed acute cholangitis in adults, including severe, refractory or complex cases and failed ERCP. Children: use a paediatric pathway.
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Hepatobiliary SurgeryEmergency
Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18)
Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18): Acute cholangitis: HPB pathway (adult) → Vital signs first; resuscitate and diagnose → Antibio...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Action Vital signs first; resuscitate and diagnose
If shocked or confused, start resuscitation and antibiotics now. Do not wait for the diagnosis.
- TG18 diagnosis: A (fever >38 °C or rigors, or WBC <4 or >10 x10^9/L, or CRP >=10 mg/L) plus B (bilirubin >=34 µmol/L, or ALP, GGT, AST or ALT >1.5 x ULN) or C (bile duct dilatation or a cause on imaging)
- Suspected: A plus B or C. Definite: A plus B plus C
- Bloods: FBC, UEC, LFTs, albumin, CRP, INR, lactate. Ultrasound first; CT or MRCP for the cause and level
- Involve the HPB team early for: grade III; failed or impossible ERCP; altered anatomy (e.g. Roux-en-Y); hilar or suspected malignant obstruction; bile duct injury, liver transplant or post-operative biliary problem; recurrent cholangitis
- Give analgesia early; it does not hide the diagnosis
03Action Antibiotics now: within 1 h if septic shock
Within 6 h in other patients, and always before drainage. Adult doses. Check penicillin allergy, renal function and pregnancy before choosing.
- Community-acquired: amoxicillin 2 g IV 6-hourly + gentamicin 4-5 mg/kg IV first dose (up to 7 mg/kg in septic shock; ideal or adjusted body weight) + metronidazole 500 mg IV 12-hourly
- Gentamicin: further doses only per local protocol with levels; none if CrCl <40 mL/min; stop empirical gentamicin by 48 h. Unsuitable (e.g. myasthenia gravis): piperacillin-tazobactam 4.5 g IV 6-hourly instead. Adjust other doses to renal function
- Non-severe penicillin allergy: ceftriaxone 2 g IV daily (1 g IV 12-hourly if septic shock) + metronidazole 500 mg IV 12-hourly. Severe penicillin allergy: gentamicin + clindamycin 600 mg IV 8-hourly and ID advice
- Pregnancy: gentamicin can still be used (first dose 4-7 mg/kg; further doses per local protocol), or piperacillin-tazobactam 4.5 g IV 6-hourly. Involve obstetrics
- Healthcare-associated, biliary stent or recent biliary procedure: piperacillin-tazobactam 4.5 g IV 6-hourly. Known MDR organism: meropenem 1 g IV 8-hourly and ID advice
- Blood cultures first if this causes no delay; bile culture at drainage; then directed therapy. Duration: 4-7 days after source control; at least 2 weeks if Enterococcus or Streptococcus bacteraemia
04Action Grade severity (TG18); re-grade if worse
Grade III: any 1 organ dysfunction. Grade II: any 2 risk criteria and no organ dysfunction. Grade I: neither.
- Grade III (any 1): hypotension needing noradrenaline (any dose) or dopamine >=5 µg/kg/min; reduced consciousness; PaO2/FiO2 <300; oliguria or creatinine >177 µmol/L; INR >1.5; platelets <100 x10^9/L
- Grade II (any 2): WBC >12 or <4 x10^9/L; temperature >=39 °C; age >=75 years; bilirubin >=85 µmol/L; albumin <0.7 x lower limit of normal
- Grade I: meets neither set of criteria
05Warning Grade III (severe): organ support, then urgent drainage
Admit to ICU. Drain as soon as initial resuscitation allows. If no ICU or drainage on site, transfer now.
- Organ support: fluids (reassess often; caution in heart failure or dialysis), vasopressors, ventilation
- Drainage only (endoscopic or percutaneous); treat stones or the cause after recovery
- Coagulopathy or anticoagulants: drain with a stent, no sphincterotomy; see the bleeding-risk step
06Action Grade II (moderate): early biliary drainage
Endoscopic or percutaneous drainage within 48 h; re-grade and drain urgently if worse. If drainage is not available on site, transfer to a hospital that provides it.
07Decision Biliary drainage needed now?
Yes: grade III or II, or grade I with a CBD stone or no response to antibiotics within 24 h. No: grade I and improving.
- If Yes
08Warning Anticoagulant, antiplatelet or coagulopathy: bleeding risk
Before ERCP or PTBD, ask about anticoagulants and antiplatelets and check INR and platelets. Do not delay drainage in severe cholangitis.
- Drain with a stent or nasobiliary drain; avoid sphincterotomy
- Remove stones at a later session; papillary balloon dilation may be better than sphincterotomy
- Plan anticoagulant and antiplatelet management with the proceduralist
09Action Biliary drainage: ERCP first line
Endoscopic transpapillary drainage (stent or nasobiliary drain) is first line. Antibiotics must already be running. Send bile for culture.
- Sphincterotomy is not needed for drainage alone
- Grade I-II with CBD stones: sphincterotomy and stone removal can be done at the same ERCP, unless on anticoagulants or coagulopathic. Large or multiple stones: remove at a second ERCP
- Pregnancy: ERCP is still indicated; minimise fluoroscopy and involve obstetrics
- Altered anatomy (e.g. Roux-en-Y): balloon enteroscopy-assisted ERCP where expertise exists; otherwise PTBD or EUS-guided drainage
- Suspected malignant or hilar obstruction: discuss stent type with the HPB team before placement
10Decision Endoscopic drainage done and successful?
No: ERCP failed or not possible, or altered anatomy without enteroscopy expertise.
- If Yes
11Action After drainage: check response
Review daily. If not improving, repeat imaging and check the drain.
- Clinical review, LFTs and inflammatory markers daily until improving
- Monitor drain output and position
- Not improving: look for an undrained segment, liver abscess, bile leak or blocked stent
- Adjust antibiotics to blood and bile cultures
12Action Treat the cause once the patient is stable
After the patient's general condition has improved.
- CBD stones: clear the duct (ERCP or surgical exploration). Gallbladder stones: plan cholecystectomy unless unfit
- Malignant obstruction: staging and HPB MDT review before definitive stent or surgery
- Bile duct injury: refer to a specialist HPB centre for repair
- Benign stricture or recurrent cholangitis after biliary-enteric anastomosis: endoscopic, percutaneous or surgical treatment per HPB team
13End Discharge with a plan for the cause
Arrange definitive treatment of the cause and HPB follow-up before discharge.
If No14Action ERCP failed or not possible: PTBD or EUS-guided drainage
Percutaneous transhepatic biliary drainage (PTBD). EUS-guided drainage is an alternative where expertise exists.
- Also for duodenal obstruction or an inaccessible papilla
- Image-guided (ultrasound and fluoroscopy); external drain first, internalise later
- High bleeding-risk procedure: check INR and platelets and plan anticoagulants with IR
- Ascites raises the risk of bleeding and bile leak: discuss the route with IR
15Decision PTBD or EUS drainage successful?
Duct drained and patient improving.
- If Yes
- Path rejoins step 11Shared downstream outcome
If No16Warning All drainage failed: surgical drainage (last resort)
Only when endoscopic and percutaneous drainage fail or are not possible. High morbidity in the acute setting.
- Aim: decompress the duct (e.g. CBD exploration and T-tube)
- Defer definitive repair or bypass until sepsis has resolved
- Cholecystostomy does not reliably drain an obstructed bile duct
- Path rejoins step 11Shared downstream outcome
If No17Action Grade I, improving: continue antibiotics
Most grade I patients do not need drainage. If there is no response within 24 h, a CBD stone is found, or the patient worsens, go back to the drainage steps above.
- Path rejoins step 12Shared downstream outcome
Guideline Source
Tokyo Guidelines 2018 (TG18): initial management of acute biliary infection and flowchart for acute cholangitis
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Severity can change within hours: re-grade and escalate if the patient worsens.
- Grade II-III needs a hospital with ERCP or IR drainage and ICU: transfer early if these are not on site.
- Antibiotic regimens are adult, eTG-based empirical choices; use the local antibiogram and adjust to cultures and renal function.
- Older or immunosuppressed patients may have no fever or typical signs.
Contraindicated Populations
Children under 18 years (adult criteria and doses)
Applicable Regions
USEUAU
AU: Empirical antibiotics follow the eTG-based Victorian Adult Sepsis Pathway (2025). Lab units: creatinine 177 µmol/L = 2.0 mg/dL; bilirubin 34 and 85 µmol/L = 2 and 5 mg/dL. Gentamicin is TGA pregnancy category D; SOMANZ 2023 still uses a first dose in sepsis in pregnancy.
EU: Antibiotic choice per TG18 (Gomi 2018) and local antibiogram; TG18 adds vancomycin for Enterococcus in grade III community-acquired and in healthcare-associated cholangitis.
US: Antibiotic choice per TG18 (Gomi 2018) and local antibiogram; TG18 adds vancomycin for Enterococcus in grade III community-acquired and in healthcare-associated cholangitis.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18)?
The Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18) is a emergency clinical algorithm for Hepatobiliary Surgery. It provides a structured decision tree to guide clinical decision-making, based on Tokyo Guidelines 2018 (TG18): initial management of acute biliary infection and flowchart for acute cholangitis.
What guideline is the Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18) based on?
This algorithm is based on Tokyo Guidelines 2018 (TG18): initial management of acute biliary infection and flowchart for acute cholangitis (DOI: 10.1002/jhbp.509).
What are the limitations of the Acute Cholangitis - Hepatobiliary Surgery Pathway (TG18)?
Known limitations include: Severity can change within hours: re-grade and escalate if the patient worsens.; Grade II-III needs a hospital with ERCP or IR drainage and ICU: transfer early if these are not on site.; Antibiotic regimens are adult, eTG-based empirical choices; use the local antibiogram and adjust to cultures and renal function.; Older or immunosuppressed patients may have no fever or typical signs.. Individual patient factors may require deviation from these recommendations.
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