Acute Cholangitis

Acute cholangitis is also known as ascending cholangitis.

Potentially life-threatening system bacterial infection of the biliary tree secondary to biliary obstruction, and is classified by clinical severity into:

Epidemiology and Risk Factors

Pathophysiology

Biliary obstruction leads to a cascade of:

  • ↑ Intra-biliary pressure
  • Cholangiovenous and cholangiolymphatic reflux
  • Translocation of duodenal pathogens into he biliary tree

Aetiology

Obstruction may be due to:

  • Biliary stones
  • Occlusion of previous stents
  • Contrast reflux
  • Duct stenosis
    • Malignant
    • Post-anastomotic
      Following liver transplant.
    • Post-sphincterotomy
      After previous cholangitis.
    • Spontaneous
  • Parasite organisms

Infection is often polymicrobial, and causes include:

  • Gram positive cocci
    • Streptococcus spp.
    • Enterococcus spp.
  • Gram negative rods
    • E. coli
    • Klebsiella spp.
    • Pseudomonas spp.
    • Enterobacter spp.
  • Tropical parasites
    • Clonorchis sinensis
    • Opisthorchis spp.

Clinical Features

Features include:

  • SIRS
  • Biliary obstruction
    • Fever
    • Biliary colic
      Pain that is:
      • Steady
        i.e. Not “colicky”.
      • Severe
      • Localised to the RUQ
      • Associated with N/V
      • Following a large, fatty meal
  • Rigidity and guarding in ~30%

The classical features of Charcot’s triad occur in 43% of cases, and include:

  • Fever
  • Abdominal pain
  • Jaundice

Assessment

History:

Exam:

Investigations

Bedside:

Laboratory:

  • Blood
    • Inflammatory markers
      • CRP
      • WCC
    • LFT
    • Amylase and lipase
      For concurrent pancreatitis.
    • Coag
      • DIC
      • Procedural
    • UEC
      • AKI
    • Cultures
      Often of limited utility due to isolated and polymicrobial infection.

Imaging:

  • Ultrasound
    • Non-invasive
    • Excellent detection of duct dilation
  • CT
  • MRCP
    Greater sensitivity for:
    • Non-calcified biliary obstruction
    • Malignant obstruction

Other:

Diagnostic Approach and DDx

Diagnosis requires ⩾2 of:

  • Systemic inflammation
    • Fever/chills
    • Laboratory signs of inflammation
  • Cholestasis
    • Jaundice
    • Abnormal LFTs
      Any derangement meets criteria, an obstructive pattern is not required.
  • Imaging
    • Biliary dilatation
    • Cause identified
      e.g. Stone seen.

Differential diagnoses include:

  • Infective
    • Cholecystitis
    • RLL pneumonia
    • Pancreatitis
    • Hepatic abscess
  • Non-infective
    • Biliary malignancy

Management

  • Standard sepsis management
    Covered under Management.
  • Intra-abdominal antibiotic cover
  • Relief of obstruction

Resuscitation:

Specific therapy:

70-80% of patients will respond to antibiotics alone. Broad coverage (Gram positive, Gram negative, and anaerobes) is required due to the diversity of the possible causative pathogen.

  • Pharmacological
    • Antibiotics
      • Tazocin
      • Meropenem
  • Procedural
    Relief of biliary obstruction and drainage of infected bile with:
    • ERCP
      • Treatment of choice
      • Sphincterotomy
      • Stone removal
    • Cholecystectomy
      • Biliary stenting
    • Percutaneous Transhepatic Cholangiography
      • Balloon dilatation
      • Stenting
    • Percutaneous cholecystotomy
  • Physical

Supportive care:

Disposition:

Preventative:

Marginal and Ineffective Therapies

Anaesthetic Considerations

Complications

Prognosis

Key Studies

References