|

Acute Cholangitis

Last updated:

Overview

Also known as ascending cholangitis, acute cholangitis describes inflammation of the biliary tree, most often due to bacterial infection (typically Escherichia coli). It occurs due to partial or complete obstruction of the biliary tree. The most common predisposing factor is gallstones or malignant structures.

Pathophysiology

The biliary tree is relatively free of bacteria due to the continued movement of bile, which flushes any bacteria present into the duodenum. Immunoglobulin A (IgA) is also secreted in the bile duct epithelium, preventing bacteria from adhering to the ducts and promoting them being flushed out.

Obstruction (e.g. due to gallstones), increases the pressure of bile ducts and overwhelms these protective mechanisms, leading to inflammation and increased ‘gaps’ between the bile duct epithelial cells. Bile contaminated with bacteria comes into contact with the blood resulting in bacteraemia.

Causes

Partial or complete obstruction of the biliary tree can predispose to the development of acute cholangitis. Causes include:

  • Gallstones – most common
  • Benign or malignant bile duct structures or stenosis
  • Tumours – pancreatic cancer, cholangiocarcinoma etc.
  • Endoscopic retrograde cholangiopancreatography (ERCP) – may introduce bacteria

Epidemiology

  • Up to 9% of people admitted to hospital with gallstone disease have acute cholangitis
  • Acute cholangitis often affects people aged 50-60 years old
  • Around 1% of people develop acute cholangitis secondary to ERCP

Presentation

Overview

The classic presentation of acute cholangitis is the presence of Charcot’s triad, which is seen in up to 50-70% of patients:

  • Fever – most common, seen in 90% of people
  • Right upper quadrant pain – seen in up to 65% of people
  • Jaundice – seen in up to 60% of people

Up to 20% of people present with hypotension and altered mental status due to septic shock. These features in addition to Charcot’s triad are known as Reynold’s pentad.

Investigations

Overview

  • Full blood count (FBC):
    • May show leukocytosis suggesting inflammation and infection
  • C-reactive protein (CRP):
    • Non-specific marker of inflammation, may be elevated
  • Liver function tests (LFTs):
    • Bilirubin, ALP, and gamma-GT are often raised
    • As time goes on, transaminases may become elevated 
  • Urea and electrolytes (U&Es):
    • May show renal dysfunction if septic shock develops
  • Blood cultures:
    • Identifies causative organism if sepsis is present
  • Abdominal ultrasound – often performed first-line:
    • Often used in people with right upper quadrant pain to screen for bile duct stones, strictures, or other causes of obstruction etc.
  • Endoscopic retrograde cholangiopancreatography (ERCP):
    • The gold-standard diagnostic test and may also be therapeutic as it can be used for biliary stone extraction
    • Allows for direct observation of the cause of obstruction (e.g. stones)

Differential Diagnoses

Biliary colic

  • Episodes of intermittent, crampy right upper quadrant pain
  • Symptoms often occur after eating meals, particularly fatty meals
  • Nausea is often common

Acute cholecystitis

  • Features of acute cholangitis are similar to acute cholecystitis
  • Jaundice is not usually present in acute cholecystitis
  • Murphy’s sign is associated with acute cholecystitis. It is rarely seen in acute cholangitis 

Viral hepatitis

  • Right upper quadrant pain may be associated with flu-like symptoms such as malaise, myalgia, lethargy, and nausea
  • There may be a history of risk factors such as foreign travel, intravenous drug use, getting tattoos etc.

Acute pancreatitis

  • Usually due to gallstones or consuming a large amount of alcohol over a short period
  • Often severe epigastric or periumbilical pain that radiates to the back
  • Cullen’s sign or Grey-Turner’s sign may be present in severe pancreatitis

Acute coronary syndrome

  • Pain is generally central chest pain or in the epigastrium and is described as squeezing or crushing
  • There may be radiation to the jaw or shoulder and associated sweating and pallor
  • Risk factors of cardiovascular disease may be present

Management

Overview

  • 1st-line: stabilise the patient with IV antibiotics, fluids, correction of coagulopathy etc. and arrange ERCP after 24-48 hours
    • Using ERCP allows for stone removal, dilatation of strictures, stenting, and biopsies

If ERCP is not suitable or unsuccessful, percutaneous transhepatic cholangiography may be considered. Laparoscopic surgery is usually a last resort. 

Complications

  • Severe sepsis and shock, resulting in multiple organ failure and death:
    • The leading cause of death
  • Acute pancreatitis:
    • Common bile duct stones obstruct the flow of pancreatic secretions
    • Pancreatitis may also be a complication of ERCP
  • Formation of liver abscesses and liver failure

Prognosis

  • In mild cases in the absence of septic shock, the majority of patients (up to 80-90%) have a good prognosis with early treatment
  • Septic shock, advanced age, hypoalbuminaemia, and underlying malignancy are associated with a worse prognosis

Author