Charcot's triad: fever, jaundice, RUQ abdominal pain Risk factors: - biliary stent in place - ERCP within 48 hours - gallstones - pancreatic head cancer / upper GI obstructing mass  - parasitic infections (eg clonorchis) **microbio** - gram negatives: e coli, klebsiella, enterobacter, pseudomonas - gram positives: enterococcus, stretococcus, other anaerobes **Treatment** - [[ERCP vs. MRCP|ERCP]] - pip-taz and metronidazole (or ceftriaxone and metro if penicillin sensitive not anaphylactic - cipro + flagyl if anaphylaxis to penicillin other options (not common exam topics) - Percutaneous transhepatic cholangiography (PTCC) - Occasionally ERCP is not technically feasible or fails to establish biliary drainage. In such cases, biliary drainage can often be achieved by percutaneous transhepatic cholangiography. - the bile duct can be decompressed by inserting a needle into the liver and draining the pus that way. PTC can also be used to put stents in, image the duct, extract stones, etc. - Percutaneous cholecystostomy - if the gall bladder is accessible, the simplest thing would be to put a drain into it (just as in the case of acalculous cholecystitis)