Dr. Elizabeth Squirell

Acute cholangitis

Tokyo criteria and grade, antibiotics by setting, timing of ERCP, and what to do if ERCP fails

Reviewed October 2026 · For healthcare professionals. Follow your local protocols.

Tools: Acute cholangitis (Tokyo 2018)

Is it this? (TG18)

Category Items
A. Systemic inflammation Fever >38 °C or shaking chills; or WBC <4 or >10 ×10⁹/L, or CRP ≥10 mg/L
B. Cholestasis Bilirubin ≥34.2 µmol/L (2 mg/dL); or ALP, GGT, AST or ALT >1.5× ULN
C. Imaging Biliary dilatation; or a cause on imaging (stone, stricture, stent)
  • Suspected: one A + one B or C.
  • Definite: one A + one B + one C.

Grade it (TG18)

Grade III (severe): any organ dysfunction:

  • hypotension needing dopamine ≥5 µg/kg/min or any norepinephrine
  • decreased level of consciousness
  • PaO₂/FiO₂ <300
  • oliguria or creatinine >176.8 µmol/L (2.0 mg/dL)
  • INR >1.5
  • platelets <100 ×10⁹/L

Grade II (moderate): any two of:

  • WBC >12 or <4 ×10⁹/L
  • temperature ≥39 °C
  • age ≥75
  • bilirubin ≥85.5 µmol/L (5 mg/dL)
  • albumin <0.7× the lower limit of normal

Grade I (mild): neither.

Orders

  • Blood cultures before antibiotics; send bile for culture at the start of drainage (TG18).
  • Ultrasound first (SIS/IDSA 2010); CT or MRCP if the cause or anatomy is unclear.
  • INR and platelets before ERCP. Hold anticoagulants and correct coagulopathy as appropriate.
  • IV fluids, analgesia, and ICU review for grade III.

Antibiotics (empiric, adult, normal renal function)

Setting Suggested choice Dose
Community, grade I–II Ceftriaxone 1–2 g IV every 24 h
Community, grade II (alternative) Piperacillin-tazobactam 3.375 g IV every 6 h
Community grade III, or healthcare-associated (any grade) Piperacillin-tazobactam 3.375 g IV every 6 h (4.5 g every 6 h if Pseudomonas is a concern)
or meropenem 1 g IV every 8 h
or cefepime ± metronidazole 2 g IV every 8–12 h; metronidazole 500 mg IV every 8–12 h
plus vancomycin for Enterococcus 15–20 mg/kg IV every 8–12 h (levels per local protocol)
Severe β-lactam allergy, community grade I–II Ciprofloxacin or levofloxacin ± metronidazole, if local susceptibility allows 400 mg IV every 12 h; 750 mg IV every 24 h
Severe β-lactam allergy, community grade III or healthcare-associated Aztreonam ± metronidazole, plus vancomycin (fluoroquinolones are not a TG18 option here) 1–2 g IV every 6–8 h
  • Agent choices: TG18 (Gomi 2018, Table 3). Doses: SIS/IDSA 2010, Table 6.
  • Anaerobic cover (metronidazole) only if there is a biliary-enteric anastomosis (TG18; SIS/IDSA). Piperacillin-tazobactam and carbapenems already cover anaerobes.
  • TG18 advises against ampicillin-sulbactam where E. coli resistance exceeds 20%. Many ESBL organisms are fluoroquinolone-resistant.
  • Use your local antibiogram; adjust for renal function and allergy per local protocol.

Duration: 4–7 days once the source is controlled. At least 2 weeks if Enterococcus or Streptococcus bacteremia (TG18). After successful drainage of moderate or severe cholangitis, 4 days was non-inferior to 8 days in a randomized trial (Srinu 2024); be more cautious with malignant obstruction, incomplete drainage or shock at presentation.

Scope: when

Grade TG18 ESGE 2019
III (severe) Drain as soon as possible after initial resuscitation and organ support As soon as possible; within 12 h if septic shock
II (moderate) Early drainage Within 48–72 h
I (mild) Antibiotics; drain if no response to initial treatment Elective

ASGE 2021 suggests decompression within 48 h. Guidelines differ on exact hours; reassess a grade II patient often and drain sooner if they worsen.

How to drain

  • ERCP is first line, over percutaneous drainage (TG18; ASGE 2021).
  • Unstable patient or coagulopathy: decompression only (plastic stent or nasobiliary drain). Sphincterotomy is not needed just to drain and is avoided with anticoagulants or coagulopathy (TG18).
  • Stable patient: sphincterotomy and stone removal in the same session is reasonable (ASGE 2021; TG18 for grade I–II). Large or multiple stones: drain now, clear later.

If ERCP fails or isn’t possible

  • Percutaneous transhepatic biliary drainage (PTBD) via IR.
  • EUS-guided biliary drainage where expertise exists, including after failed ERCP in altered anatomy (TG18).
  • Do not let a failed ERCP delay source control: call IR the same day for grade II–III.

Disposition

  • Grade III: ICU or step-down.
  • Gallstones: laparoscopic cholecystectomy within 2 weeks of ERCP (ESGE 2019) to cut recurrent biliary events. Refer to surgery before discharge.

Pitfalls

  • Waiting for “definite” criteria before treating a septic patient.
  • Treating a grade II patient with antibiotics alone and no plan for drainage.
  • Adding metronidazole to piperacillin-tazobactam or a carbapenem.
  • Forgetting vancomycin in grade III or healthcare-associated cholangitis (TG18).
  • Discharging without a cholecystectomy plan.

Follow your local protocols and antibiogram.

Sources

  1. Kiriyama S, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci 2018;25:17–30. PMID 29032610 TG18 adopts the TG13 diagnostic and severity criteria unchanged.
  2. Kiriyama S, et al. New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo Guidelines. J Hepatobiliary Pancreat Sci 2012;19:548–556. PMID 22825491 Tables 4 and 7: the criteria and thresholds (fever >38 °C; WBC <4 or >10; CRP ≥1 mg/dL; bilirubin ≥2 mg/dL; enzymes >1.5× ULN; organ dysfunction definitions; grade II items).
  3. Gomi H, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2018;25:3–16. PMID 29090866 Table 3 agents by grade and setting (fluoroquinolones for community grade I–II only, footnote e: if susceptibility known or β-lactam allergy; aztreonam ± metronidazole for grade III and healthcare-associated); vancomycin for grade III and healthcare-associated; anaerobic cover only with biliary-enteric anastomosis; antibiotics within 1 h in septic shock; 4–7 days after source control; ≥2 weeks for Enterococcus or Streptococcus bacteremia; bile culture at drainage.
  4. Miura F, et al. Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci 2018;25:31–40. PMID 28941329 Grade I: antibiotics, drain if no response; grade II: early drainage; grade III: drainage as soon as possible after organ support.
  5. Mukai S, et al. Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018. J Hepatobiliary Pancreat Sci 2017;24:537–549. PMID 28834389 Endoscopic transpapillary drainage first line; sphincterotomy not required for drainage alone; avoid sphincterotomy with anticoagulants or coagulopathy; EUS-guided drainage as an alternative to PTBD where expertise exists.
  6. Manes G, et al. Endoscopic management of common bile duct stones: ESGE guideline. Endoscopy 2019;51:472–491. PMID 30943551 Drainage timing by TG18 grade: severe as soon as possible and within 12 h if septic shock; moderate within 48–72 h; mild elective. Laparoscopic cholecystectomy within 2 weeks of ERCP.
  7. Buxbaum JL, et al. ASGE guideline on the management of cholangitis. Gastrointest Endosc 2021;94:207–221. PMID 34023065 Endoscopic over percutaneous drainage; decompression within 48 h; sphincterotomy and stone removal at the same session unless too unstable.
  8. Srinu D, Shah J, Jena A, et al. Conventional vs short duration of antibiotics in patients with moderate or severe cholangitis: noninferiority randomized trial. Am J Gastroenterol 2024;119:176–82. PMID 37732816 n=120, single centre (India), after successful drainage: 4 vs 8 days, clinical cure 78.0% vs 79.7% (non-inferior); malignant cause and hypotension predicted lower cure.
  9. Solomkin JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by SIS and IDSA. Clin Infect Dis 2010;50:133–164. PMID 20034345 Table 6 adult IV doses (normal renal function), including aztreonam 1–2 g every 6–8 h; anaerobic cover in cholangitis only with biliary-enteric anastomosis.
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