Prevent cholangiovenous reflux by decompressing the duct system.-uncontrolled sepsis and the consequent multisystem organ failure are the life-threatening sequelae of acute toxic cholangitis. thus, the initial goal of treatment is to decompress the biliary duct system to prevent reflux of bacteria and their toxic products into the circulation. this can be done by intubating the duct system through the percutaneous, transhepatic, or the endoscopic route or by insertion of a t tube in the common duct at operation. removal of the stone causing the obstruction is not necessary to stabilize the patient. only after the duct is decompressed should the cause of the obstruction be addressed. when transhepatic biliary drainage has been used, endoscopic or surgical removal of the stone can be carried out after the patient has recovered completely. when initial therapy is sphincterotomy, the stone should be removed as part of the procedure. often the stone falls out without manipulation. if surgical placement of a t tube is the initial treatment, the stone should be removed only if it is convenient to do so. the long-range goal of treatment of patients with bile duct obstruction is to prevent cirrhosis, ascites, portal hypertension, and hemorrhage from esophageal varices; however, death from sepsis is the immediate threat in acute toxic cholangitis. gallstone pancreatitis may occur in patients who have an impacted stone in the distal duct, independent of the presence or absence of acute toxic cholangitis; however, gallstone pancreatitis is more often associated with the passage of a stone into the duodenum.