Acute cholangitis is an infectious disease of the biliary tract with a wide spectrum of presentation ranging in severity from a mild form with fever and jaundice, to a severe form with septic shock. Supportive care with hydration, antibiotics, and biliary decompression remain the cornerstones of care. Broad-spectrum antibiotics should include coverage of E.coli, Klebsiella sp., Enterococcus sp., and in severely critically ill patients, coverage of additional pathogens such as Bacteriodes sp., Pseudomonas, and yeast should be considered. Biliary decompression should be performed early in the course of the illness when the patient has not improved or if they worsen with hydration and antibiotics. Stable patients should have biliary decompression usually within 72 hours when the fever has resolved. Urgent decompression with a percutaneous or endoscopic stent is preferred over an operative decompression in most institutions. Outcome is dependent on the etiology of the obstruction (benign versus malignant) and the ability to achieve biliary decompression.