Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Diagnosis and management of acute cholangitis

Abstract

Bacterial infection that occurs in the setting of biliary obstruction can lead to acute cholangitis, a condition characterized by fever, abdominal pain and jaundice. Choledocholithiasis is the most common cause of acute cholangitis and is often associated with bacterial infection and colonization in addition to biliary obstruction. Iatrogenic introduction of bacteria into the biliary system most commonly occurs during endoscopic retrograde cholangiopancreatography in patients with biliary obstruction. The majority of patients with acute cholangitis respond to antibiotic therapy, but endoscopic biliary drainage is ultimately required to treat the underlying obstruction. Acute cholangitis is often diagnosed using the clinical Charcot triad criteria; however, recommendations from an international consensus meeting in Tokyo produced the most comprehensive recommendations for the diagnosis and management of acute cholangitis. These guidelines enable a more accurate diagnosis of acute cholangitis than do earlier methods, and they facilitate the classification of disease as mild, moderate or severe. Although these guidelines represent a notable advance toward defining a universally accepted consensus for the definition of acute cholangitis, they have several limitations. This Review discusses current recommendations for the diagnosis of acute cholangitis and addresses the advantages and disadvantages of different modalities for the treatment of this disease.

Key Points

  • Diagnosis of acute cholangitis has traditionally been made by the Charcot triad criteria; that is, clinical findings of fever, biliary tract pain and jaundice

  • Approximately 80% of patients with acute cholangitis respond to broad-spectrum antibiotics alone while the remainder require early biliary drainage in addition to antibiotic therapy

  • Endoscopic retrograde cholangiopancreatography (ERCP) and stent placement are considerably safer than surgical biliary decompression

  • Elective cholecystectomy should be performed after resolution of acute cholangitis in patients with an intact gallbladder

  • Meticulous disinfection and ERCP techniques are required to avoid the development of acute cholangitis in patients with biliary obstruction who undergo ERCP

This is a preview of subscription content, access via your institution

Relevant articles

Open Access articles citing this article.

Access options

Buy article

Get time limited or full article access on ReadCube.

$32.00

All prices are NET prices.

Figure 1: Diagnostic criteria for acute cholangitis.
Figure 2: Diagnosis and management algorithm for acute cholangitis.

References

  1. Leung, J. W. et al. Antibiotics, biliary sepsis, and bile duct stones. Gastrointest. Endosc. 40, 716–721 (1994).

    CAS  PubMed  Google Scholar 

  2. Leung, J. W. et al. Bacteriologic analyses of bile and brown pigment stones in patients with acute cholangitis. Gastrointest. Endosc. 54, 340–345 (2001).

    CAS  PubMed  Google Scholar 

  3. Newman, H. F. & Northup, J. D. The autopsy incidence of gallstones. Surg. Gynecol. Obstet. 109, 1–13 (1959).

    CAS  PubMed  Google Scholar 

  4. Jorgensen, T., Kay, L. & Schultz-Larsen, K. The epidemiology of gallstones in a 70-year-old Danish population. Scand. J. Gastroenterol. 25, 335–340 (1990).

    CAS  PubMed  Google Scholar 

  5. The MICOL Group. In Recent Advances in the Epidemiology and Prevention of Gallstone Disease (eds Capocaccia, L. et al.) 37–44 (Kluwer, Boston, 1991).

  6. Everhart, J. E., Khare, M., Hill, M. & Maurer, K. R. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 117, 632–639 (1999).

    CAS  PubMed  Google Scholar 

  7. Neuhaus, H. et al. Prospective evaluation of the use of endoscopic retrograde cholangiography before laparoscopic cholecystectomy. Endoscopy 24, 745–749 (1992).

    CAS  PubMed  Google Scholar 

  8. Saltzstein, E. C., Peacock, J. B. & Thomas, M. D. Preoperative bilirubin, alkaline phosphatase and amylase levels as predictors of common duct stones. Surg. Gynecol. Obstet. 154, 381–384 (1982).

    CAS  PubMed  Google Scholar 

  9. Lacaine, F., Corlette, M. B. & Bismuth, H. Preoperative evaluation of the risk of common bile duct stones. Arch. Surg. 115, 1114–1116 (1980).

    CAS  PubMed  Google Scholar 

  10. Houdart, R., Perniceni, T., Darne, B., Salmeron, M. & Simon, J. F. Predicting common bile duct lithiasis: determination and prospective validation of a model predicting low risk. Am. J. Surg. 170, 38–43 (1995).

    CAS  PubMed  Google Scholar 

  11. Welbourn, C. R., Mehta, D., Armstrong, C. P., Gear, M. W. & Eyre-Brook, I. A. Selective preoperative endoscopic retrograde cholangiography with sphincterotomy avoids bile duct exploration during laparoscopic cholecystectomy. Gut 37, 576–579 (1995).

    CAS  PubMed  PubMed Central  Google Scholar 

  12. McSherry, C. K., Ferstenberg, H., Calhoun, W. F., Lahman, E. & Virshup, M. The natural history of diagnosed gallstone disease in symptomatic and asymptomatic patients. Ann. Surg. 202, 59–63 (1985).

    CAS  PubMed  PubMed Central  Google Scholar 

  13. Friedman, G. D. Natural history of asymptomatic and symptomatic gallstones. Am. J. Surg. 165, 399–404 (1993).

    CAS  PubMed  Google Scholar 

  14. Charcot, J. M. Lecons sur les maladies du fore des voices biliares et des veins faites à la Faculté de Médicine de Paris [French]. (Recueillies et publliées par Bournesville et Sevestre, Paris, 1877) English translation (New York, 1878).

    Google Scholar 

  15. Lai, E. C. et al. Endoscopic biliary drainage for severe acute cholangitis. N. Engl. J. Med. 326, 1582–1586 (1992).

    CAS  PubMed  Google Scholar 

  16. Leung, J. W., Chung, S. C., Sung, J. J., Banez, V. P. & Li, A. K. Urgent endoscopic drainage for acute suppurative cholangitis. Lancet 1, 1307–1309 (1989).

    CAS  PubMed  Google Scholar 

  17. Wada, K. et al. Diagnostic criteria and severity assessment of acute cholangitis: Tokyo guidelines. J. Hepatobiliary Pancreat. Surg. 14, 52–58 (2007).

    Google Scholar 

  18. Huang, T., Bass, J. A. & Williams, R. D. The significance of biliary pressure in cholangitis. Arch. Surg. 98, 629–632 (1969).

    CAS  PubMed  Google Scholar 

  19. Clements, W. D. et al. Role of the gut in the pathophysiology of extrahepatic biliary obstruction. Gut 39, 587–593 (1996).

    CAS  PubMed  PubMed Central  Google Scholar 

  20. Raper, S. E., Barker, M. E., Jones, A. L. & Way, L. A. Anatomic correlates of bacterial cholangiovenous reflux. Surgery 105, 352–359 (1989).

    CAS  PubMed  Google Scholar 

  21. Sung, J. Y. et al. Bacterial invasion of the biliary system by way of the portal venous system. Hepatology 14, 313–317 (1991).

    CAS  PubMed  Google Scholar 

  22. Sung, J. Y. et al. Ascending infection of the biliary tract after surgical sphincterotomy and biliary stenting. J. Gastroenterol. Hepatol. 7, 240–245 (1992).

    CAS  PubMed  Google Scholar 

  23. Sung, J. Y., Costerton, J. W. & Shaffer, E. A. Defense system in the biliary tract against bacterial infection. Dig. Dis. Sci. 37, 689–696 (1992).

    CAS  PubMed  Google Scholar 

  24. Subhani, J. M., Kibbler, C. & Dooley, J. S. Review article: antibiotic prophylaxis for endoscopic retrograde cholangiopancreatography (ERCP). Aliment. Pharmacol. Ther. 13, 103–116 (1999).

    CAS  PubMed  Google Scholar 

  25. Parks, R. W. et al. Intestinal barrier dysfunction in clinical and experimental obstructive jaundice and its reversal by internal biliary drainage. Br. J. Surg. 83, 1345–1349 (1996).

    CAS  PubMed  Google Scholar 

  26. Parks, R. W. et al. Change in gastrointestinal morphology associated with obstructive jaundice. J. Pathol. 192, 526–532 (2000).

    CAS  PubMed  Google Scholar 

  27. Sileri, P. et al. Bacterial translocation and intestinal morphological findings in jaundiced rats. Dig. Dis. Sci. 4, 929–934 (2002).

    Google Scholar 

  28. Csendes, A. et al. Common bile duct pressure in patients with common bile duct stones with or without acute suppurative cholangitis. Arch. Surg. 123, 697–699 (1988).

    CAS  PubMed  Google Scholar 

  29. Kuzu, M. A. et al. Obstructive jaundice promotes bacterial translocation in human. Hepatogastroenterology 46, 2159–2164 (1999).

    CAS  PubMed  Google Scholar 

  30. White, J. S., Hoper, M., Parks, R. W., Clements, W. D. & Diamond, T. Patterns of bacterial translocation in experimental biliary obstruction. J. Surg. Res. 132, 80–84 (2006).

    CAS  PubMed  Google Scholar 

  31. Flemma, R. J., Flint, L. M., Osterhaout, S. & Shingleton, W. W. Bacteriologic studies of biliary infection. Ann. Surg. 166, 563–572 (1967).

    CAS  PubMed  PubMed Central  Google Scholar 

  32. Yamamoto, S. et al. The effect of biliary decompression on antibiotic biliary excretion. Hepatogastroenterology 49, 330–334 (2002).

    PubMed  Google Scholar 

  33. Rerknimitr, R. et al. Microbiology of bile in patients with cholangitis or cholestasis with and without plastic biliary endoprosthesis. Gastrointest. Endosc. 56, 885–889 (2002).

    PubMed  Google Scholar 

  34. Landau, O., Kott, I., Deutsch, A. A., Stelman, E. & Reiss, R. Multifactorial analysis of septic bile and septic complications in biliary surgery. World J. Surg. 16, 962–965 (1992).

    CAS  PubMed  Google Scholar 

  35. Csendes, A., Diaz, J. C., Burdiles, P., Maluenda, F. & Morales, E. Risk factors and classification of acute suppurative cholangitis. Br. J. Surg. 79, 655–658 (1992).

    CAS  PubMed  Google Scholar 

  36. Reynolds, B. M. & Dargan, E. L. Acute obstructive cholangitis. A distinct clinical syndrome. Ann. Surg. 150, 200–304 (1959).

    Google Scholar 

  37. Takahashi, Y., Takahashi, T., Takahashi, W. & Sato, T. Morphometrical evaluation of extrahepatic bile ducts in reference to their structural changes with aging. Tohoku J. Exp. Med. 147, 301–309 (1985).

    CAS  PubMed  Google Scholar 

  38. Feng, B. & Song, Q. Does the common bile duct dilate after cholecystectomy? Sonographic evaluation in 234 patients. AJR Am. J. Roentgenol. 165, 859–861 (1995).

    CAS  PubMed  Google Scholar 

  39. Wachsberg, R. H., Kim, K. H. & Sundaram, K. Sonographic versus endoscopic retrograde cholangiographic measurements of the bile duct revisited: importance of the transverse diameter. AJR Am. J. Roentgenol. 170, 669–674 (1998).

    CAS  PubMed  Google Scholar 

  40. Bachar, G. N., Cohen, M., Belenky, A., Atar, E. & Gideon, S. Effect of aging on the adult extrahepatic bile duct: a sonographic study. J. Ultrasound Med. 22, 879–882 (2003).

    Google Scholar 

  41. Behar, J. et al. Functional gallbladder and sphincter of Oddi disorders. Gastroenterology 130, 1498–1509 (2006).

    PubMed  Google Scholar 

  42. Holzknecht, N. et al. Breath-hold MR cholangiography with snapshot techniques: prospective comparison with endoscopic retrograde cholangiography. Radiology 206, 657–664 (1998).

    CAS  PubMed  Google Scholar 

  43. Lomas, D. J., Bearcroft, P. W. & Gimson, A. E. MR cholangiopancreatography: prospective comparison of a breath-hold 2D projection technique with diagnostic ERCP. Eur. Radiol. 9, 1411–1417 (1999).

    CAS  PubMed  Google Scholar 

  44. Varghese, J. C. et al. A prospective comparison of magnetic resonance cholangiopancreatography with endoscopic retrograde cholangiopancreatography in the evaluation of patients with suspected biliary tract disease. Clin. Radiol. 54, 513–520 (1999).

    CAS  PubMed  Google Scholar 

  45. Varghese, J. C. et al. Diagnostic accuracy of magnetic resonance cholangiopancreatography and ultrasound compared with direct cholangiography in the detection of choledocholithiasis. Clin. Radiol. 55, 25–35 (2000).

    CAS  PubMed  Google Scholar 

  46. Soto, J. A., Barish, M. A., Alvarez, O. & Medina, S. Detection of choledocholithiasis with MR cholangiography: comparison of three-dimensional fast spin-echo and single- and multisection half-Fourier rapid acquisition with relaxation enhancement sequences. Radiology 215, 737–745 (2000).

    CAS  PubMed  Google Scholar 

  47. Demartines, N. et al. Evaluation of magnetic resonance cholangiography in the management of bile duct stones. Arch. Surg. 135, 148–152 (2000).

    CAS  PubMed  Google Scholar 

  48. Guarise, A., Baltieri, S., Mainardi, P. & Faccioli, N. Diagnostic accuracy of MRCP in choledocholithiasis [Italian]. Radiol. Med. 109, 239–251 (2005).

    PubMed  Google Scholar 

  49. Amouyal, P. et al. Diagnosis of choledocholithiasis by endoscopic ultrasonography. Gastroenterology 106, 1062–1067 (1994).

    CAS  PubMed  Google Scholar 

  50. Sugiyama, M. & Atomi, Y. Endoscopic ultrasonography for diagnosing choledocholithiasis: a prospective comparative study with ultrasonography and computed tomography. Gastrointest. Endosc. 45, 143–146 (1997).

    CAS  PubMed  Google Scholar 

  51. Verma, D., Kapadia, A., Eisen, G. M. & Adler, D. G. EUS vs MRCP for detection of choledocholithiasis. Gastrointest. Endosc. 64, 248–254 (2006).

    PubMed  Google Scholar 

  52. Sgouros, S. N. & Bergele, C. Endoscopic ultrasonography versus other diagnostic modalities in the diagnosis of choledocholithiasis. Dig. Dis. Sci. 51, 2280–2286 (2006).

    PubMed  Google Scholar 

  53. Ozden, I. et al. Endoscopic and radiologic interventions as the leading causes of severe cholangitis in a tertiary referral center. Am. J. Surg. 189, 702–706 (2005).

    PubMed  Google Scholar 

  54. Einstein, D. M., Lapin, S. A., Ralls, P. W. & Halls, J. M. The insensitivity of sonography in the detection of choledocholithiasis. AJR Am. J. Roentgenol. 142, 725–728 (1984).

    CAS  PubMed  Google Scholar 

  55. Mitchell, S. E. & Clark, R. A. A comparison of computed tomography and sonography in choledocholithiasis. AJR Am. J. Roentgenol. 142, 729–733 (1984).

    CAS  PubMed  Google Scholar 

  56. Polkowski, M., Palucki, J., Regula, J., Tilszer, A. & Butruk, E. Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: a prospective blinded study in non-jaundiced patients. Gut 45, 744–749 (1999).

    CAS  PubMed  PubMed Central  Google Scholar 

  57. Kondo, S. et al. Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography. Eur. J. Radiol. 54, 271–275 (2005).

    PubMed  Google Scholar 

  58. Reiss, R., Eliashiv, A. & Deutsch, A. A. Septic complications and bile cultures in 800 consecutive cholecystectomies. World J. Surg. 6, 195–199 (1982).

    CAS  PubMed  Google Scholar 

  59. Siegman-Igra, Y., Isakov, A., Inbar, G. & Cahaner, J. Pseudomonas aeruginosa septicaemia following endoscopic retrograde cholangiopancreatography with a contaminated endoscope. Scand. J. Infect. Dis. 19, 527–530 (1987).

    CAS  PubMed  Google Scholar 

  60. Sinanan, M. Acute cholangitis. Infect. Dis. Clin. North Am. 6, 571–599 (1992).

    CAS  PubMed  Google Scholar 

  61. Hanau, L. & Steigbigel, N. Cholangitis: pathogenesis, diagnosis, and treatment. Curr. Clin. Top. Infect. Dis. 15, 153–178 (1995).

    CAS  PubMed  Google Scholar 

  62. Westphal, J. & Brogard, J. Biliary tract infections: a guide to drug treatment. Drugs 57, 81–91 (1999).

    CAS  PubMed  Google Scholar 

  63. Hanau, L. & Steigbigel, N. Acute (ascending) cholangitis. Infect. Dis. Clin. North Am. 14, 521–546 (2000).

    CAS  PubMed  Google Scholar 

  64. Swidsinski, A. & Lee, S. P. The role of bacteria in gallstone pathogenesis. Front. Biosci. 6, E93–E103 (2001).

    CAS  PubMed  Google Scholar 

  65. Kumar, R., Sharma, B. C., Singh, J. & Sarin, S. K. Endoscopic biliary drainage for severe acute cholangitis in biliary obstruction as a result of malignant and benign diseases. J. Gastroenterol. Hepatol. 19, 994–997 (2004).

    PubMed  Google Scholar 

  66. Tanaka, A. et al. Antimicrobial therapy for acute cholangitis: Tokyo guidelines. J. Hepatobiliary Pancreat. Surg. 14, 59–67 (2007).

    PubMed  PubMed Central  Google Scholar 

  67. van Lent, A. U. et al. Duration of antibiotic therapy for cholangitis after successful endoscopic drainage of the biliary tract. Gastrointest. Endosc. 55, 518–522 (2002).

    PubMed  Google Scholar 

  68. Carpenter, C. F. & Swami, A. Cholangitis. Johns Hopkins POC-IT ABX Guide (Ed. Barlett, J. G.) [online], (2008).

    Google Scholar 

  69. Leung, J. W., Chan, R. C., Cheung, S. W., Sung, J. Y. & Chung, S. C. S. The effect of obstruction on the biliary excretion of cefoperazone and ceftriaxone. J. Antimicrob. Chemother. 25, 399–406 (1990).

    CAS  PubMed  Google Scholar 

  70. Williams, E. J. et al. Guidelines on the management of common bile duct stones (CBDS). Gut 57, 104–121 (2008).

    Google Scholar 

  71. Attasaranya, S., Fogel, E. L. & Lehman, G. A. Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis. Med. Clin. North Am. 92, 925–960 (2008).

    PubMed  Google Scholar 

  72. Hui, C. K. et al. Acute cholangitis—predictive factors for emergency ERCP. Aliment. Pharmacol. Ther. 15, 1633–1637 (2001).

    CAS  PubMed  Google Scholar 

  73. National Institutes of Health State-of-the-Science Conference Statement on Endoscopic Retrograde Cholangiopancreatography (ERCP) for Diagnosis and Therapy [online], (2002).

  74. Adler, D. G. et al. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas. Gastrointest. Endosc. 62, 1–8 (2005).

    PubMed  Google Scholar 

  75. Speer, A. G. et al. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 2, 57–62 (1987).

    CAS  PubMed  Google Scholar 

  76. Sugiyama, M. & Atomi, Y. Treatment of acute cholangitis due to choledocholithiasis in elderly and younger patients. Arch. Surg. 132, 1129–1133 (1997).

    CAS  PubMed  Google Scholar 

  77. Sugiyama, M. & Atomi, Y. The benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis. Am. J. Gastroenterol. 93, 2065–2068 (1998).

    CAS  PubMed  Google Scholar 

  78. Deviere, J. et al. Septicaemia after endoscopic retrograde cholangiopancreatography. Endoscopy 22, 72–75 (1990).

    CAS  PubMed  Google Scholar 

  79. Gigot, J. F. et al. Acute cholangitis: multivariate analysis of risk factors. Ann. Surg. 209, 435–438 (1988).

    Google Scholar 

  80. Hintze, R. E. et al. Magnetic resonance cholangiopancreatography-guided unilateral endoscopic stent placement for Klatskin tumours. Gastrointest. Endosc. 53, 40–46 (2001).

    CAS  PubMed  Google Scholar 

  81. Harewood, G. C. & Baron, T. H. Cost analysis of magnetic resonance cholangiography in the management of inoperable hilar biliary obstruction. Am. J. Gastroenterol. 97, 1152–1158 (2003).

    Google Scholar 

  82. Lee, D. W. et al. Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: a prospective randomized trial. Gastrointest. Endosc. 56, 361–365 (2002).

    PubMed  Google Scholar 

  83. De Palma, G. D., Galloro, G., Siciliano, S., Iovino, P. & Catanzano, C. Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study. Gastrointest. Endosc. 53, 547–553 (2001).

    CAS  PubMed  Google Scholar 

  84. Chopra, K. B. et al. Randomised study of endoscopic biliary endoprosthesis versus duct clearance for bile duct stones in high risk patients. Lancet 348, 791–793 (1996).

    CAS  PubMed  Google Scholar 

  85. Feitoza, A. B. & Baron, T. H. Endoscopy and ERCP in the setting of previous upper GI tract surgery. Part I: reconstruction without alteration of pancreaticobiliary anatomy. Gastrointest. Endosc. 54, 743–749 (2001).

    CAS  PubMed  Google Scholar 

  86. Feitoza, A. B. & Baron, T. H. Endoscopy and ERCP in the setting of previous upper GI tract surgery. Part II: postsurgical anatomy with alteration of the pancreaticobiliary tree. Gastrointest. Endosc. 55, 75–79 (2002).

    PubMed  Google Scholar 

  87. Koornstra, J. J., Fry, L. & Monkemuller, K. ERCP with the balloon-assisted enteroscopy technique: a systematic review. Dig. Dis. 26, 324–329 (2008).

    PubMed  Google Scholar 

  88. Gupta, N., Rajwanshi, A., Srinivasan, R. & Nijhawan, R. Pathology of supraclavicular lymphadenopathy in Chandigarh, north India: an audit of 200 cases diagnosed by needle aspiration. Cytopathology 17, 94–96 (2006).

    CAS  PubMed  Google Scholar 

  89. Taylor, K. J. W., Rosenfield, A. T. & Spiro, H. M. Diagnostic accuracy of grey scale ultrasonography for the jaundiced patient. A report of 275 cases. Arch. Intern. Med. 139, 60–63 (1979).

    CAS  PubMed  Google Scholar 

  90. Hakansson, K., Ekberg, O., Hakansson, H. O. & Leander, P. MR and ultrasound in screening of patients with suspected biliary tract disease. Acta Radiol. 43, 80–86 (2002).

    CAS  PubMed  Google Scholar 

  91. Romagnuolo, J. et al. Magnetic resonance cholangiopancreatography: a meta analysis of test performance in suspected biliary disease. Ann. Intern. Med. 139, 547–557 (2003).

    PubMed  Google Scholar 

  92. Hammarstrom, L. E., Holmin, T., Stridbeck, H. & Ihse, I. Long term follow up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ. Br. J. Surg. 82, 1516–1521 (1995).

    CAS  PubMed  Google Scholar 

  93. Targarona, E. M. et al. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high risk patients. Lancet 347, 926–929 (1996).

    CAS  PubMed  Google Scholar 

  94. Boerma, D. et al. Wait and see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile duct stones. A randomised trial. Lancet 360, 761–765 (2002).

    PubMed  Google Scholar 

  95. Lau, J. Y. et al. Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients. Gastroenterology 130, 96–103 (2006).

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to John G. Lee.

Ethics declarations

Competing interests

The author declares no competing financial interests.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Lee, J. Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol 6, 533–541 (2009). https://doi.org/10.1038/nrgastro.2009.126

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrgastro.2009.126

This article is cited by

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing