• Clinical science

Acute cholangitis

Abstract

Acute cholangitis (also known as ascending cholangitis) is an infection of the biliary tract. It is caused by obstruction of the biliary tree, which may lead to bile stasis and subsequent bacterial infection. Clinically it is characterized by Charcot's cholangitis triad, consisting of abdominal pain (usually RUQ), high fever, and jaundice, although this last sign is not always present. Sepsis and septic shock may develop as a complication of acute cholangitis. Diagnosis is suspected in patients with fever and laboratory tests showing inflammation, along with either jaundice or abnormal liver enzymes, and is confirmed if there is etiological evidence (e.g., cholelithiasis, tumor compressing the biliary tracts) or biliary tract dilation on imaging. Treatment includes monitoring and resuscitation (if sepsis is present), antibiotic coverage, and biliary drainage.

Epidemiology

  • Sex: =
  • Incidence: up to 9% of patients with cholelithiasis
  • Peak incidence: 50–60 years

References:[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Obstruction of biliary tracts (e.g., caused by biliary lithiasis, stenosis, or malignancy), with secondary bacterial infection
  • May follow cholecystitis
  • Ascending infection most commonly from the duodenum after manipulation of bile tract (e.g., papillotomy, stent placement, post-ERCP) due to disruption of normal barrier mechanisms

References:[2]

Pathophysiology

  • Biliary tract obstruction (choledocholithiasis, biliary strictures, tumors) + bile stasis → ↑ bactibilia → infection develops, affecting the biliary tract and possibly ascending into hepatic ducts

References:[2]

Clinical features

References:[3]

Diagnostics

  • Leukocytosis, CRP
  • Signs of cholestasis (↑ bilirubin, ↑ ALP), often ↑ AST/ALT
  • Ultrasound (first imaging procedure): shows biliary dilation and/or evidence of an etiology (e.g., cholelithiasis)
  • In some cases, a CT scan may be diagnostic
  • In severe/unstable cases in which acute cholangitis is suspected, conduct emergency ERCP (both diagnostic and therapeutic)

References:[2]

Treatment

  • Approach
    • Initial treatment: broad-spectrum antibiotics and supportive therapy
    • In mild cases: continue conservative therapy (results in clinical improvement in ∼ 80% of cases) → elective ERCP within 24–48 hours of improvement
    • If severe disease (e.g., signs of sepsis) or condition worsens despite conservative therapy → emergency biliary drainage
  • Monitoring and resuscitation
    • Fluid and electrolyte correction
    • Severe/unstable cases → ICU
  • Broad-spectrum antibiotics
  • Biliary drainage
    • Indications
      • In severe cases or disease refractory to conservative therapy: perform immediately
      • For patients who respond to conservative therapy: perform within 24–48 hours of clinical improvement
    • ERCP is the treatment of choice, possibly in combination with:
      • Sphincterotomy (for cholangitis due to lithiasis or choledocholithiasis)
      • or Stent insertion (acute suppurative cholangitis)
    • Percutaneous transhepatic cholangiography (PTC)
      • Indicated if ERCP is unsuccessful or unavailable.
  • Interval cholecystectomy: if associated with gallstones
    • Prevents recurrence of cholangitis or other complications as a result of gallstone disease
    • Recommended with 6 weeks

References:[2][3][4]

  • 1. Drug Ther Bull. What if it's acute cholangitis?. Drug Ther Bull. 2015; 43(8): pp. 62–64. doi: 10.1136/dtb.2005.43862.
  • 2. Scott TM. Acute Cholangitis. In: Brenner BE. Acute Cholangitis. New York, NY: WebMD. http://emedicine.medscape.com/article/774245. Updated November 21, 2016. Accessed April 7, 2017.
  • 3. Afdhal NH. Acute Cholangitis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/acute-cholangitis. Last updated March 18, 2016. Accessed April 7, 2017.
  • 4. Li VK, Yum JL, Yeung YP. Optimal timing of elective laparoscopic cholecystectomy after acute cholangitis and subsequent clearance of choledocholithiasis. Am J Surg. 2010; 200(4): pp. 483–488. doi: 10.1016/j.amjsurg.2009.11.010.
  • Sodikoff J, Hirano I. Therapeutic strategies in eosinophilic esophagitis: Induction, maintenance and refractory disease. Best Pract Res Clin Gastroenterol. 2015: pp. 829–839. doi: 10.1016/j.bpg.2015.09.002.
last updated 06/06/2018
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