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  • Often a history of biliary pain, which may be accompanied by jaundice.

  • Occasional patients present with painless jaundice.

  • Nausea and vomiting.

  • Cholangitis should be suspected with fever followed by hypothermia and gram-negative shock, jaundice, and leukocytosis.

  • Stones in bile duct most reliably detected by ERCP or EUS.


About 15% of patients with gallstones in the gallbladder have choledocholithiasis (bile duct stones). The percentage rises with age, and the frequency in older adults with gallstones may be as high as 50%. Bile duct stones usually originate in the gallbladder but may also form spontaneously in the bile duct after cholecystectomy. The risk is increased twofold in persons with a juxtapapillary duodenal diverticulum. Symptoms and possible cholangitis result if there is obstruction.


A. Symptoms and Signs

A history of biliary pain or jaundice may be obtained. Biliary pain results from rapid increases in bile duct pressure due to obstructed bile flow. The features that suggest the presence of a bile duct stone are (1) frequently recurring attacks of right upper abdominal pain that is severe and persists for hours, (2) chills and fever associated with severe pain, and (3) a history of jaundice associated with episodes of abdominal pain (Table 18–9). The combination of right upper quadrant pain, fever (and chills), and jaundice represents Charcot triad and denotes the classic picture of acute cholangitis. The addition of altered mental status and hypotension (Reynolds pentad) signifies acute suppurative cholangitis and is an endoscopic emergency. According to the Tokyo guidelines (revised in 2018), the diagnosis of acute cholangitis is established by an elevated WBC signifying systemic inflammation and elevated cholestatic liver biochemical test levels or imaging evidence of biliary dilatation, or both; these criteria also allow grading by the severity of cholangitis. The BILE criteria have also been proposed for the diagnosis of acute cholangitis: biliary imaging abnormalities, inflammatory test abnormalities, liver test abnormalities, and exclusion of cholecystitis and acute pancreatitis.

Hepatomegaly may be present in calculous biliary obstruction, and tenderness is usually present in the right upper quadrant and epigastrium. Bile duct obstruction lasting more than 30 days results in liver damage leading to cirrhosis. Hepatic failure with portal hypertension occurs in untreated cases. In a population-based study from Denmark, acute cholangitis was reported to be a marker of occult GI cancer.

B. Laboratory Findings

Acute obstruction of the bile duct typically produces a transient albeit striking increase in serum aminotransferase levels (often greater than 1000 U/L [20 mckat/L]). Bilirubinuria and elevation of the serum bilirubin are present if the bile duct remains obstructed; levels commonly fluctuate. Serum alkaline phosphatase levels rise more slowly. Not uncommonly, serum amylase elevations are present because of secondary ...

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