• Also known as "ascending cholangitis"
  • Requires the presence of biliary obstruction and infected biliary tract

Anatomy & Pathophysiology

Gallbladder anatomy
  • Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
  • These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
  • Bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.

Gallbladder disease types


  • Choledocholithiasis
  • Biliary tract stricture
  • Compression by malignant disease

Clinical Features

Differential Diagnosis

RUQ Pain


MRCP image of two stones in the distal common bile duct


  • Labs
    • Leukocytosis with neutrophil predominance
    • Elevated alk phos and conjugated bilirubin
    • GGT elevation much more sensitive than alk phos
    • Blood cultures
  • Imaging
    • RUQ Ultrasound
      • Dilatation of CBD ( > 6mm) and presence of choledocholithiasis
      • May miss small CBD stones and in acute cases CBD may not have had time to dilate
  • ERCP
    • Should be obtained to confirm the diagnosis and for possible intervention


  • Aggressive sepsis resuscitation


Coverage is targeted at E. coli, Enterococcus, Bacteroides, and Clostridium (anerobic)

  • expand coverage for MRSA if severe sepsis or septic shock
    • Vancomycin 15-20mg/kg PLUS any of the following options


Involvement with GI for ERCP and general surgery for acute cholecystectomy is necessary for source control and biliary decompression


  • Admit

See Also