Acute cholangitis remains a life-threatening complication of biliary obstruction, particularly in the elderly with comorbid disease or when there is a delay in diagnosis and treatment. The initial management consists of fluid resuscitation, correction of coagulopathy, and administration of broad-spectrum antibiotics. The choice of antibiotics should cover both gram-negative and gram-positive organisms associated with cholangitis until the results of a blood culture are available. The timing and choice of biliary decompression varies depending on the response to antibiotic therapy, the presence of comorbid disease, and the underlying cause. Biliary sepsis resolves in most patients with conservative treatment, thus allowing time to perform more detailed non-interventional imaging (e.g., spiral computed tomography [CT], magnetic resonance cholangiopancreatography [MRCP]) to determine the underlying cause and level of biliary obstruction. Those with cholangitis who do not respond to conservative therapy will require urgent biliary decompression. In patients with choledocholithiasis, endoscopic drainage is now the treatment of choice or, if this fails, transhepatic biliary decompression is a useful alternative. Various endoscopic options are available for managing choledocholithiasis, ranging from endoscopic papillotomy (EP) and extraction of stones, to the placement of a biliary drainage system. In patients who respond to antibiotic therapy, EP with stone extraction is preferred, while in those with ongoing sepsis and multiple large stones, the placement of a stent with or without an EP is the safest option. Transhepatic biliary drainage is now reserved for failure of endoscopic drainage and for patients with suspected hilar cholangiocarcinoma or intrahepatic stones. Surgical biliary decompression is seldom required in the emergency setting, but still plays an important role in the definitive treatment of the underlying cause.