In this episode of Hospital Medicine Unplugged, we cut through ascending cholangitis—recognize fast, resuscitate early, hit bugs hard, drain the duct.

We open with the do-firsts: aggressive IV fluids, hemodynamic stabilization, early broad-spectrum antibiotics, and urgent source control planning. Loop in GI/advanced endoscopy, interventional radiology, surgery, and ICU from the start.

How to call it—diagnosis without delay: fever, RUQ pain, jaundice (Charcot’s triad) when present, plus labs of infection + cholestasis and imaging (US first; CT or MRCP if equivocal) showing ductal dilation/obstruction. Remember: the triad is insensitive—don’t wait for all three.

Stratify with Tokyo Guidelines because timing rides on severity:
• Grade III (severe) = organ dysfunction → emergent biliary decompression + ICU care.
• Grade II (moderate) = high fever, WBC extremes, age ≥75, Tbili ≥5, hypoalbuminemia, local inflammation → early drainage.
• Grade I (mild) = start antibiotics + observe response; drain if no improvement.

Antibiotics—cover what’s common and what counts: Enterobacterales + Enterococcus, consider Pseudomonas/ESBL in healthcare-associated disease or prostheses. Typical choices: piperacillin–tazobactam for community-acquired without high-risk features; escalate to a carbapenem (± VRE coverage per local ecology) for severe/MDRO risk. Tailor to cultures. Duration is usually 3–5 days after source control.

Source control—the main event:
• ERCP within 48–72 hours for most, and sooner for moderate/severe disease: sphincterotomy ± stone extraction, balloon sweep/basket, temporary stent if needed. Early ERCP links to lower mortality, less organ failure, shorter LOS.
• If ERCP isn’t feasible: percutaneous transhepatic biliary drainage (PTBD), EUS-guided drainage, or surgical decompression—choose the fastest, safest route in your shop.
• Malignant or complex strictures: prioritize decompression now (temporary stent), definitive oncologic work-up later.

ICU & adjuncts that matter: blood cultures before antibiotics (when it won’t delay therapy), correct coagulopathy, manage vasopressors judiciously, watch for AKI and post-ERCP pancreatitis. Reassess daily: vitals, mental status, bilirubin/ALP/AST/ALT, WBC/CRP, renal function, lactate. If fevers or labs stall, re-image and re-drain.

Pitfalls you can dodge:
• Delaying drainage in Grade II/III.
• Narrow empiric coverage too soon in stented/recurrent or healthcare-associated cases.
• Missing atypical older/immunocompromised presentations (no fever/jaundice).
• Skipping Enterococcus coverage where prostheses or prior ERCPs suggest it.

We close with the system moves—build a cholangitis bundle that: (1) screens with “fever + RUQ pain/jaundice or cholestasis” → STAT US (then CT/MRCP as needed); (2) gives antibiotics in triage; (3) auto-pages GI/IR/ICU for Grade II/III; (4) targets ERCP ≤48–72 h (sooner if severe) with a time-to-drainage KPI; (5) standardizes antibiotic narrowing to culture data; (6) bakes in post-ERCP monitoring and re-imaging triggers; (7) routes malignant/benign strictures to definitive follow-up after stabilization.

Bottom line: resuscitate, cover, and decompress—fast. Early ERCP changes outcomes; protocols make it reliable.