Cholangitis overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farwa Haideri [2]

Cholangitis Microchapters
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Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Cholangitis from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
Diagnostic Criteria
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X Ray
CT
MRI
Ultrasound
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
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Overview

Cholangitis is an infection of the bile duct, which transports bile from the liver to the intestines and the gallbladder. Symptoms include fever, right upper quadrant pain, and jaundice due to the infection of the bile duct and inflammation of the biliary tree, which is usually the result of obstruction and stasis.

Historical Perspective

• Dr. Jean-Martin Charcot, a French physician, is credited with discovering the disease in the late 19th century. He referred to the condition as "hepatic fever."
  • Charcot's triad of fever, jaundice, and right upper quadrant abdominal pain is the classical presentation of cholangitis.
  • By adding septic shock and mental status changes to the list of symptoms, Dr. B. M. Reynolds and Dr. Everett L. Dargan changed Charcot's triad to Reynold's pentad.
• Until 1968, the mainstay of treatment of cholangitis was surgery, with exploration of the bile duct and excision of gallstones, until the advent of endoscopic retrograde cholangiopancreatography (ERCP).

Classification

Acute cholangitis is classified into grade I, II, or III, depending on the severity of the condition.

Pathophysiology

Cholangitis involves two main factors: an increase in the bacterial presence and elevated intraductal pressure in the bile duct, both of which allow for the translocation of bacteria or endotoxins in the vascular system. Bacterial contamination alone does not usually result in cholangitis. Increased pressure in the biliary system, from obstruction in the bile duct, widens the spaces between the cells lining the duct, which brings bacterially contaminated bile into the bloodstream.

Causes

Cholangitis is usually caused by a bacterial infection, which can occur due to blockage in the duct, such as from a gallstone or tumor. The infection causing this condition may also spread to the liver.

Differential Diagnosis

Cholangitis must be differentiated from other causes of infection in the common bile duct, as well as from inflammation and infection of cholecystitis.

Epidemiology and Demographics

Cholangitis is most prevalent in adults, with roughly 20% of the adult population suffering from some form of abdominal pain from gallstones passing through the bile duct into the digestive tract.

Risk Factors

Common risk factors in the development of cholangitis are gallstones, sclerosing cholangitis, and HIV. Variations in treatment and risk factors influence mortality rates in patients with cholangitis, and these rates underscore the necessity for standardized diagnostic, treatment, and severity assessment criteria.

Screening

There are no established screening processes for cholangitis or cholangiocarcinoma, a cancer associated with this disease. There are methods to detect the early onset of both diseases.

Natural History, Complications, and Prognosis

Patients who show early signs of multiple organ failure (renal failure, disseminated intravascular coagulation, alterations in the level of consciousness, and shock) or evidence of acute cholangitis, as well as those who do not respond to conservative treatment, should receive systemic antibiotics and undergo emergent biliary drainage. Unless early and appropriate biliary drainage is performed and systemic antibiotics are administered, death will occur. Prognosis is usually good with treatment, but poor without it.

Diagnosis

History and Symptoms

Obtaining a complete and accurate history is the most important aspect of making a diagnosis of cholangitis. It provides insight into cause, precipitating factors, and associated comorbid conditions.

Physical Examination

Charcot's triad, which includes abdominal pain, jaundice, and fever, describes three common findings in cholangitis. Reynold's pentad, which includes Charcot's triad and two other symptoms, septic shock and mental confusion, also provides common markers in a physical examination for cholangitis. Cholangitis is associated with significant morbidity and mortality.

Laboratory Findings

Laboratory tests provide useful clues in the diagnosis of cholangitis. Some commonly conducted tests include complete blood count, basic metabolic panel, liver function tests, blood culture, and other body fluid cultures.

X-Ray

X-rays are not the most useful tool for diagnosing cholangitis. X-rays are mainly used to obtain a visual impression of the biliary system once an endoscopic retrograde cholangiopancreatography (ERCP) has been conducted.

CT

CT scans may be helpful in locating, with high sensitivity, the site of the obstruction responsible for a case of cholangitis.

MRI

Magnetic resonance imaging (MRI) has become the standard method for morphological examination of the bile ducts, particularly for diagnosing cholangitis. T1-weighted and T2-weight sequences offer different results.

Ultrasound

Ultrasounds (US) are the primary imaging modality for cholangitis. An US is both sensitive and specific in demonstrating biliary dilatation.

Other Imaging Findings

Magnetic resonance cholangiopancreatography (MRCP) and endoscopic sonography (EUS) are the most sensitive techniques to correctly determine the underlying cause and level of biliary obstruction in patients with acute cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) is also considered a gold standard test for biliary obstruction.

Other Diagnostic Studies

Blood tests to check levels of liver enzymes are the first step in diagnosing cholangitis. Doctors can confirm the diagnosis using cholangiography, which provides pictures of the bile ducts.

Diagnostic Criteria

Shown below are the diagnostic criteria for acute cholangitis according to Tokyo guidelines:

• The diagnosis is "suspected" in the case of the presence of one item in systemic inflammation with one item in either cholestasis or imaging findings.
• The diagnosis is "definite" in the case of the presence of one item in systemic inflammation, one item in cholestasis, and one item in imaging.

Clinical Manifestations	Changes from the baseline
Systemic inflammation	♦ Fever >38℃ and/or shaking chills ♦ Evidence of inflammatory response: - WBC (×1000/μl) <4, or >10 - CRP (mg/dl) ≥1
Cholestasis	♦ Jaundice with total bilirubin ≥2 (g/dl) ♦ Abnormal liver function tests: - ALP (IU) >1.5×STD - γGTP (IU) >1.5×STD - AST (IU) >1.5×STD - ALT (IU) >1.5×STD
Imaging findings	♦ Biliary dilatation ♦ Evidence of the etiology (stricture, stone, stent, etc.) on imaging (abdominal X-ray: KUB, abdominal USG, CT scan, MRI, MRCP and HIDA scan)

Severity Assessment Criteria

The severity assessment criteria for acute cholangitis according to Tokyo guidelines is as follows.

Grade III Acute Cholangitis

Grade III or severe acute cholangitis is characterized by the onset of dysfunction in at least one of the following:

• Cardiovascular system: decreased blood pressure that necessitate the administration of dopamine (>5 μg/kg/min) or norepinephrine
• Neurological system: abnormal consciousness
• Respiratory system: PaO2/FiO2 ratio <300
• Renal system: serum creatinine >2.0 mg/dl, decreased urine output
• Hepatic system: PT-INR >1.5
• Hematological system: platelet count < 100,000/mm³

Grade II Acute Cholangitis

Grade II or moderate acute cholangitis is characterized by the presence of any two of the following:

• Abnormal WBC count: >12,000/mm³, <4,000/mm³
• Fever ≥39°C
• Age ≥75 years
• Elevated total bilirubin ≥5 mg/dl
• Decreased albumin level <0.7 x STD

Grade I Acute Cholangitis

Grade I or mild acute cholangitis does not meet the criteria of neither grade II (moderate) or grade III (severe) acute cholangitis.

Treatment

Medical Therapy

Antimicrobial therapy is indicated for acute cholangitis. Patients with community- acquired mild to moderate disease are treated with Cephalosporins. All other patients are treated with a combination of Metronidazole and either Imipenem-Cilastatin, Meropenem, Doripenem, Piperacillin-Tazobactam, Ciprofloxacin, Levofloxacin, or Cefepime.

Surgery

Surgery is not the preferred technique to improve the outcome of cholangitis. Initial management in patients can be conserved through proper antibiotics, as the majority of them can resolve symptoms.

Primary Prevention

Although reestablishing biliary drainage is the mainstay of treatment, antibiotics play an important role in the management of cholangitis.

Secondary Prevention

Secondary prevention strategies for cholangitis include continued treatment of predisposing causes in appropriate patients.

Cost-Effectiveness of Therapy

The most cost-effective technique to diagnose cholangitis is an ultrasound.

References

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