Acute cholangitis (ascending cholangitis)

What is cholangitis?

Cholangitis is inflammation of the biliary tract. It is normally due to infection and as a result may cause septicaemia and sepsis. Therefore it is a surgical emergency.

Pathophysiology

There are 3 main causes of acute cholangitis:

1. Biliary obstruction - due to gallstones (most common) or cholangiocarcinoma.
2. Iatrogenic - due to infection introduced during ERCP (endoscopic retrograde cholangiopancreatography).
3. Carcinoma - either a cholangiocarcinoma or head of pancreas cancer.

💡

ERCP uses a combination of endoscopy and X-ray for diagnosis and treatment of pancreatic, hepatic and biliary issues. The endoscope is guided through the GI tract to the duodenum. However, it may introduce infection into gallbladder, biliary tree, pancreas.

🦠 Causative agents

The 3 main causative agents are:

1. E. coli (27%)
2. Klebsiella spp. (16%)
3. Enterococcus spp. (15%)

😷 Symptoms

🔺

Charcot’s triad:

• Fever (in 90% of patients)
• RUQ pain (in 70% of patients)
• Jaundice (in 60% of patients)

If we add hypotension and confusion we can make it Reynold’s pentad ➡️

5️⃣

Reynold’s pentad

• Fever (in 90% of patients)
• RUQ pain (in 70% of patients)
• Jaundice (in 60% of patients)
• Hypotension
• Confusion

💡

Jaundice usually is present when bilirubin is >35umol/L

🕵🏽 Differential diagnosis

As it is almost always caused by an underlying cause, we need to identify this cause and so cholangitis is not a full diagnosis.

🔍 Investigations

🥇

Imaging

• Ultrasound - is usually first line. A common bile duct > 6mm suggests dilatation. We can also use US to look for gallstones or the cause of an obstruction.
• MRCP is an excellent modality to visualize gallstones, but is also excellent to view strictures and malignancy. Poor renal function is not a contraindication for MRCP. It is not first-line as it is not as readily available and is more expensive but it is less invasive than ERCP.

🏆

ERCP is the gold standard investigation for cholangitis. However, ERCP is invasive and therefore carries much more risk than the imaging modalities mentioned above. As a result, it is frequently preceded by MRCP where available.

🩸

Bloods FBC - leucocytosis ⬆️ seen in most patients

LFTs - ALP ⬆️ 

GGT ⬆️ 

🧰 Management

Patients with cholangitis often present with sepsis and therefore they should be promptly managed with the sepsis 6.

🥇 Early IV antibiotics is necessary - gentamicin is often first-line.

🏆 ERCP ± sphincterectomy & stenting - the majority of patients diagnosed with ascending cholangitis will undergo ERCP after 24-48 hours to relieve any obstruction.

🥈 Percutaneous transhepatic cholangiography (PTC)

🚨 Complications

• Sepsis - this is more common in cholangitis, as the sludge can get backed up into the liver which is very vascular and more likely to lead to a bacteraemia.
• Gallbladder empyema - this is an abscess within the gallbladder. It is often refractory to IV antibiotics and requires drainage.