# Cholangitis - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Cholangitis - StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK558946/ · ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class DD82.00 - condition scope only, no dose · Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis (J Hepatobiliary Pancreat Sci 2018;25:3-16, tokyo-guidelines-2018-antimicrobial-jhbp518.pdf) · Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) - Verified date: 2026-08 ## Verified against - Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis (J Hepatobiliary Pancreat Sci 2018;25:3-16, tokyo-guidelines-2018-antimicrobial-jhbp518.pdf) - Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) ## Treatment metadata - Ceftriaxone — 1000 mg — injection - Referral & safety-netting (no drug therapy) ## Complete treatment card ```text CHOLANGITIS Sources: Cholangitis - StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK558946/ · ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class DD82.00 - condition scope only, no dose · Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis (J Hepatobiliary Pancreat Sci 2018;25:3-16, tokyo- guidelines-2018-antimicrobial-jhbp518.pdf) · Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) Review status: REVIEWED against 2 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (4) - The illness spans mild disease through fever, chills, feeling unwell, shaking, widespread belly pain, jaundice, itching, and pale stools, up to overwhelming sepsis [abdominal pain · chills · fever · itching · jaundice · malaise · pale stools · sepsis · tremor] - Prior gallstones, a recent gallbladder removal or ERCP, past cholangitis, or HIV/AIDS raise the risk of this infection [gallstones] - Patients generally look markedly unwell and often present already in severe sepsis or septic shock [sepsis · shock] - Roughly 90% of patients run a fever, and 60 to 70% are jaundiced [fever] SIGNS - what you find (3) - Exam findings can include fever, tenderness in the upper right belly, jaundice, a distended abdomen, confusion, or unstable blood pressure [abdominal distension · confusion · fever · jaundice] - The Charcot triad of fever, right-upper-belly pain, and jaundice is very specific (95.9%) but misses most cases (26.4% sensitive) [abdominal pain · fever · jaundice] - Adding confusion and sepsis to the classic triad forms the Reynolds pentad [confusion · sepsis] TESTS (10) - The 2018 Tokyo criteria catch essentially every case (100% sensitive) and are far more specific (87.4%) than the classic triad - Tokyo diagnosis needs two of the three classic findings plus signs of systemic inflammation, abnormal liver tests, and imaging showing duct dilatation with a cause such as stones or strictures - A high neutrophil count is typical, while a low white count instead shows up in septic or immunocompromised patients - Liver tests show a blocked-flow pattern with raised bilirubin, alkaline phosphatase, and GGT - Abdominal ultrasound is the first imaging test ordered and is highly accurate for the gallbladder and duct dilatation - A normal ultrasound does not exclude ascending infection of the bile ducts - Thickened duct walls, dilated ducts including the common bile duct, gallstones, and pus are the classic ultrasound picture - CT scanning is poor at picking up stones lodged in the common bile duct - MRCP is the best noninvasive test for finding common bile duct stones - ERCP both pinpoints the blockage and treats it, and allows biopsy or culture samples to be taken IF NOT THIS - what else fits (2) - Other liver and biliary disease to rule out includes acute cholecystitis, hepatitis, cirrhosis, liver failure, or a hepatic abscess - Other abdominal and systemic causes to exclude include pancreatitis, a perforated ulcer, appendicitis, diverticulitis, a kidney infection, gut ischemia, or sepsis from elsewhere Source StatPearls "Cholangitis" - disease-level clinical article Status traced to the source above Rx: Empirical antibiotic started before urgent biliary drainage | Main treatment EMPIRICAL ANTIBIOTIC STARTED BEFORE URGENT BILIARY DRAINAGE 1. CEFTRIAXONE [1st line] Adult 1 to 2 g intravenously or intramuscularly, once daily or divided into two doses. Maximum 4 g daily, and no more than 2 g daily where renal and hepatic impairment are present together. - Continued in hospital: 4 to 7 days once the source of infection has been controlled, and a minimum of 2 weeks if there is bacteraemia with a gram-positive coccus such as Enterococcus or Streptococcus Peds 50-75 mg/kg/dose [child max 1000 mg] (The Egyptian formulary gives 50 to 75 mg/kg as a single daily dose for mild to moderate infection in infants, children and adolescents, with a daily ceiling of 1,000 mg - and because it is given once a day, that ceiling is also the ceiling on the single dose. For severe infection the same monograph gives 100 mg/kg per day divided every 12 to 24 hours to a maximum of 4,000 mg a day, and a premature or term neonate is given 50 mg/kg every 24 hours. Acute cholangitis in a child is rare and is usually a complication of previous biliary surgery; which of those bands applies is a judgement for the admitting team.) 3kg -> 150-225 mg/dose 4kg -> 200-300 mg/dose 5kg -> 250-375 mg/dose 6kg -> 300-450 mg/dose 7kg -> 350-525 mg/dose 8kg -> 400-600 mg/dose 9kg -> 450-675 mg/dose 10kg -> 500-750 mg/dose 11kg -> 550-825 mg/dose 12kg -> 600-900 mg/dose 13kg -> 650-975 mg/dose 14kg -> 700-1000 mg/dose (upper capped) 15kg -> 750-1000 mg/dose (upper capped) 16kg -> 800-1000 mg/dose (upper capped) 17kg -> 850-1000 mg/dose (upper capped) 18kg -> 900-1000 mg/dose (upper capped) 19kg -> 950-1000 mg/dose (upper capped) 20kg -> 1000 mg/dose (capped) 21kg -> 1000 mg/dose (capped) 22kg -> 1000 mg/dose (capped) 23kg -> 1000 mg/dose (capped) 24kg -> 1000 mg/dose (capped) 25kg -> 1000 mg/dose (capped) 26kg -> 1000 mg/dose (capped) 27kg -> 1000 mg/dose (capped) 28kg -> 1000 mg/dose (capped) 29kg -> 1000 mg/dose (capped) 30kg -> 1000 mg/dose (capped) 31kg -> 1000 mg/dose (capped) 32kg -> 1000 mg/dose (capped) 33kg -> 1000 mg/dose (capped) 34kg -> 1000 mg/dose (capped) 35kg -> 1000 mg/dose (capped) 36kg -> 1000 mg/dose (capped) 37kg -> 1000 mg/dose (capped) 38kg -> 1000 mg/dose (capped) 39kg -> 1000 mg/dose (capped) 40kg -> 1000 mg/dose (capped) 41kg -> 1000 mg/dose (capped) 42kg -> 1000 mg/dose (capped) 43kg -> 1000 mg/dose (capped) 44kg -> 1000 mg/dose (capped) 45kg -> 1000 mg/dose (capped) 46kg -> 1000 mg/dose (capped) 47kg -> 1000 mg/dose (capped) 48kg -> 1000 mg/dose (capped) 49kg -> 1000 mg/dose (capped) 50kg -> 1000 mg/dose (capped) AWaRe WATCH group - carries resistance cost. Egyptian EML 2025. Source Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) Why Two documents, each for a different claim. The Tokyo Guidelines 2018 name the agent: for grade I and grade II community-acquired acute cholangitis their cephalosporin-based options are cefazolin, cefotiam, cefuroxime, ceftriaxone or cefotaxime, and they state that antimicrobial therapy should be started before any percutaneous, endoscopic or operative drainage is performed - which is what makes a first dose in the clinic, on the way to hospital, the right move rather than a delay. The Egyptian formulary supplies the amount: it lists community-acquired intra-abdominal infection among ceftriaxone's indications and gives a general adult intravenous or intramuscular dose of 1 to 2 g once or twice daily. Egypt registers eight ceftriaxone injection products. Caution THIS IS FOR ACUTE ASCENDING BACTERIAL CHOLANGITIS, NOT FOR THE AUTOIMMUNE DISEASES OF THE SAME NAME. Primary biliary cholangitis and primary sclerosing cholangitis are long- term hepatology conditions and no antibiotic is given for them. THE ANTIBIOTIC DOES NOT REPLACE THE DRAINAGE, AND MUST NOT DELAY IT. The Tokyo Guidelines state that antimicrobial therapy should be started before any percutaneous, endoscopic or operative procedure - which means the first dose goes in on the way to hospital, not instead of going. CEFTRIAXONE IS ON THE GUIDELINE'S OWN RESISTANCE LIST. The Tokyo Guidelines carry ceftriaxone and cefotaxime in a table of agents with a high prevalence of resistance among Enterobacteriaceae, reflecting the global spread of extended-spectrum beta- lactamase producers. Where a local antibiogram shows that resistance, the guideline's answer is a carbapenem, piperacillin with tazobactam, or ceftazidime or cefepime combined with metronidazole. What the resistance rate is in any given Egyptian hospital is a local measurement, and no national figure is claimed for it. ANAEROBIC COVER IS ADDED IF THERE IS A BILIARY-ENTERIC ANASTOMOSIS - a previous operation joining bile duct to bowel. The Tokyo Guidelines warrant metronidazole, tinidazole or clindamycin in that situation only, and note that carbapenems, piperacillin with tazobactam, ampicillin with sulbactam, cefmetazole, cefoxitin, flomoxef and cefoperazone with sulbactam already have enough anti-anaerobic activity on their own. The Egyptian formulary's metronidazole monograph states no dosing regimen, so no amount is printed here. AMPICILLIN WITH SULBACTAM IS NOT AN EMPIRICAL CHOICE unless the local susceptibility is 80% or better - the Tokyo Guidelines withdraw it below that. REYNOLDS' PENTAD IS CHARCOT'S TRIAD PLUS HYPOTENSION AND CONFUSION, and is a surgical or gastroenterological emergency. Charcot's triad is fever, jaundice and right upper quadrant pain. Do not give in hypersensitivity to ceftriaxone, any component, or another cephalosporin. Do not give with an intravenous calcium-containing solution in a neonate of 28 days or less, and do not give to a jaundiced neonate, particularly a premature one, because ceftriaxone displaces bilirubin from albumin. Blood cultures before the first dose where that is possible, because the duration depends on what grows: a gram-positive coccus in the blood turns a 4 to 7 day course into a minimum of 2 weeks. Egypt ZOXIDEL 1 GM PD. FOR I.M. INJ. RAMEDA > DELT... 22.00 EGP CEFTRIAXONE SODIUM 1 GM I.M.VIAL (KAHIRA) KAHIRA 29.00 EGP ZOXIDEL 1 GM PD. FOR I.V. INJ. RAMEDA > DELT... 29.00 EGP WINTRIAXONE 1 GM PD. FOR I.V INJ. SANOFI 48.00 EGP VOTRIAXONE 1 GM I.M VIAL CHEMIPHARM 56.00 EGP OFRAMAX 1 GM I.M. VIAL RAMEDA > SUN ... 71.00 EGP TRIAXONE 1 GM I.M. VIAL TABUK PHARMAC... 106.00 EGP TRIAXONE 1 GM I.V VIAL TABUK PHARMAC... 106.00 EGP MAIN TREATMENT 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Covers acute ascending (bacterial) cholangitis — fever, jaundice, right upper quadrant pain — a biliary emergency needing same-day hospital admission for IV antibiotics and urgent biliary drainage (ERCP), as well as chronic autoimmune cholangitis (primary biliary cholangitis / primary sclerosing cholangitis) managed long-term with ursodeoxycholic acid under hepatology. GP starts empirical oral antibiotics only as a holding measure before urgent transfer for the acute form. - Refer, with advice Peds Children follow the same pathway: recognise and refer. No primary-care medicine is implied. Source No dose - referral pathway, no medicine given in primary care Why Covers acute ascending (bacterial) cholangitis — fever, jaundice, right upper quadrant pain — a biliary emergency needing same-day hospital admission for IV antibiotics and urgent biliary drainage (ERCP), as well as chronic autoimmune cholangitis (primary biliary cholangitis / primary sclerosing cholangitis) managed long-term with ursodeoxycholic acid under hepatology. GP starts empirical oral antibiotics only as a holding measure before urgent transfer for the acute form. Caution Reynolds' pentad is Charcot's triad plus hypotension and confusion, and is a surgical or GI emergency. The drug rows above are what the treating service gives. They are here so that the referral is an informed one and so the GP can recognise the regimen the patient comes back on - not as permission to start it without the referral. Charcot's triad is fever, jaundice, and right upper quadrant pain. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)