Snapshot A 56-year-old woman presents to the emergency room for skin discoloration, fevers, and abdominal pain. Her past medical history includes hyperlipidemia, obesity, diabetes, and gallstones. On physical exam, she is febrile, tachycardic, and jaundiced. She is tender to palpation in the right upper quadrant. She is alert and oriented with a normal mental status. Laboratory reveals markedly elevated alkaline phosphatase and white blood cell count. A right upper quadrant ultrasound shows intrahepatic biliary dilatation. She is started on broad-spectrum antibiotics and scheduled for an endoscopic retrograde cholangiopancreatography (ERCP). Introduction Clinical definition ascending infection of biliary tree in the setting of biliary obstruction or stasis Epidemiology Demographics incidence of up to 2% in those with gallstones Risk factors gallstones female gender age obesity ETIOLOGY Pathogenesis obstruction in the biliary tree leads to stasis and bacterial overgrowth in the bile ducts, which are typically sterile infectious agents are often gram-negative rods, Enterococcus, and anaerobes Presentation Symptoms Charcot triad jaundice fever right upper quadrant abdominal pain Reynold pentad in severe cases Charcot triad altered mental status septic shock imaging Right upper quadrant ultrasound best initial imaging findings gallstones biliary dilatation Magnetic resonance cholangiopancreatography (MRCP) high sensitivity may guide endoscopic vs surgical interventions findings dilated intrahepatic biliary ducts Studies Diagnostic testing studies ↑ white blood cell count ↑ alkaline phosphatase ↑ total and direct bilirubin mild ↑ liver enzymes DIAGNOSIS Diagnostic criteria signs of systemic inflammation fever ↑ white blood cell count cholestasis jaundice ↑ alkaline phosphatase or bilirubin imaging findings biliary dilatation visualization of obstruction Differential Acute cholecystitis distinguishing factor may develop into ascending cholangitis may or may not have ↑ alkaline phosphatase, ↑ bilirubin, or jaundice Treatment Management approach ascending cholangitis is acutely managed with antibiotics and ERCP, but patients will eventually undergo cholecystectomy First-line antibiotics drugs broad spectrum, such as cefazolin or ceftriaxone endoscopic retrograde cholangiopancreatography (ERCP) indication all patients intervention of choice can include stone removal, stent placement, or sphincterotomy Second-line percutaneous drainage indication failure of ERCP inability to perform ERCP Complications Hepatic abscesses Portal vein thrombosis