Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2] Farwa Haideri [3]
Overview
Cholangitis must be differentiated from other causes of infection in the common bile duct, as well as inflammation and infection of the gall bladder.and mainly from other causes of acute abdomen.
Differentiating Cholangitis from other Diseases
Cholangitis should be differentiated from the following:[1]
Differentiating acute cholangitis from other causes of abdominal pain
The differential diagnosis of diseases presenting with abdominal pain, fever and jaundice are discussed below.
Abbreviations:
RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram
| Classification of pain in the abdomen based on etiology
|
Disease
|
Clinical manifestations
|
Diagnosis
|
Comments
|
| Symptoms
|
Signs
|
| Abdominal Pain
|
Fever
|
Rigors and chills
|
Nausea or vomiting
|
Jaundice
|
Constipation
|
Diarrhea
|
Weight loss
|
GI bleeding
|
Hypo-
tension
|
Guarding
|
Rebound Tenderness
|
Bowel sounds
|
Lab Findings
|
Imaging
|
| Abdominal causes
|
Inflammatory causes
|
Pancreato-biliary disorders
|
Acute suppurative cholangitis
|
RUQ
|
+
|
+
|
+
|
+
|
−
|
−
|
−
|
−
|
+
|
+
|
+
|
N
|
|
- Ultrasound shows biliary dilatation/stents/tumor
|
- Septic shock occurs with features of SIRS
|
| Acute cholangitis
|
RUQ
|
+
|
−
|
−
|
+
|
−
|
−
|
−
|
−
|
−
|
−
|
−
|
N
|
|
- Ultrasound shows biliary dilatation/stents/tumor
|
- Biliary drainage (ERCP) + IV antibiotics
|
| Acute cholecystitis
|
RUQ
|
+
|
−
|
+
|
+
|
−
|
−
|
−
|
−
|
−
|
−
|
−
|
Hypoactive
|
|
Ultrasound shows:
|
|
| Acute pancreatitis
|
Epigastric
|
+
|
−
|
+
|
±
|
−
|
−
|
+
|
−
|
±
|
−
|
−
|
N
|
|
- Ultrasound shows evidence of inflammation
- CT scan shows severity of pancreatitis
|
|
| Primary sclerosing cholangitis
|
RUQ
|
+
|
−
|
−
|
+
|
−
|
−
|
−
|
−
|
−
|
−
|
−
|
N
|
|
ERCP and MRCP shows
- Multiple segmental strictures
- Mural irregularities
- Biliary dilatation and diverticula
- Distortion of biliary tree
|
- The risk of cholangiocarcinoma in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
|
| Cholelithiasis
|
RUQ/Epigastric
|
±
|
−
|
±
|
±
|
−
|
−
|
−
|
−
|
−
|
−
|
−
|
Normal to hyperactive for dislodged stone
|
|
|
|
| Gastric causes
|
Gastrointestinal perforation
|
Diffuse
|
+
|
±
|
-
|
±
|
−
|
−
|
−
|
+
|
+
|
+
|
±
|
Hyperactive/hypoactive
|
|
|
|
| Intestinal causes
|
Disease
|
Abdominal Pain
|
Fever
|
Rigors and chills
|
Nausea or vomiting
|
Jaundice
|
Constipation
|
Diarrhea
|
Weight loss
|
GI bleeding
|
Hypo-
tension
|
Guarding
|
Rebound Tenderness
|
Bowel sounds
|
Lab Findings
|
Imaging
|
Comments
|
| Inflammatory bowel disease
|
Diffuse
|
±
|
−
|
−
|
±
|
−
|
+
|
+
|
+
|
−
|
−
|
−
|
Normal or hyperactive
|
|
|
Extra intestinal findings:
|
| Whipple's disease
|
Diffuse
|
±
|
−
|
−
|
±
|
−
|
+
|
+
|
−
|
±
|
−
|
−
|
N
|
|
Endoscopy is used to confirm diagnosis.
Images used to find complications
|
Extra intestinal findings:
|
| Hepatic causes
|
Viral hepatitis
|
RUQ
|
+
|
−
|
+
|
+
|
−
|
Positive in Hep A and E
|
+
|
−
|
Positive in fulminant hepatitis
|
Positive in acute
|
+
|
N
|
- Abnormal LFTs
- Viral serology
|
|
- Hep A and E have fecal-oral route of transmission
- Hep B and C transmits via blood transfusion and sexual contact.
|
| Liver abscess
|
RUQ
|
+
|
+
|
+
|
+
|
−
|
±
|
+
|
−
|
+
|
+
|
±
|
Normal or hypoactive
|
|
|
|
| Hepatocellular carcinoma/Metastasis
|
RUQ
|
+
|
−
|
−
|
+
|
−
|
−
|
+
|
−
|
−
|
−
|
−
|
- Normal
- Hyperactive if obstruction present
|
|
|
Other symptoms:
|
| Budd-Chiari syndrome
|
RUQ
|
±
|
−
|
−
|
±
|
−
|
−
|
−
|
Positive in liver failure leading to varices
|
−
|
−
|
−
|
N
|
|
| Findings on CT scan suggestive of Budd-Chiari syndrome include:
|
|
Ascitic fluid examination shows:
|
| Peritoneal causes
|
Spontaneous bacterial peritonitis
|
Diffuse
|
+
|
−
|
−
|
Positive in cirrhotic patients
|
−
|
+
|
−
|
−
|
±
|
+
|
+
|
Hypoactive
|
- Ascitic fluid PMN>250 cells/mm³
- Culture: Positive for single organism
|
- Ultrasound for evaluation of liver cirrhosis
|
|
| Hollow Viscous Obstruction
|
Biliary colic
|
RUQ
|
−
|
−
|
+
|
+
|
−
|
−
|
−
|
−
|
−
|
−
|
−
|
N
|
|
|
|
|
References
- ↑ Miura F, Takada T, Kawarada Y, Nimura Y, Wada K, Hirota M, Nagino M, Tsuyuguchi T, Mayumi T, Yoshida M, Strasberg SM, Pitt HA, Belghiti J, de Santibanes E, Gadacz TR, Gouma DJ, Fan ST, Chen MF, Padbury RT, Bornman PC, Kim SW, Liau KH, Belli G, Dervenis C (2007). "Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg. 14 (1): 27–34. doi:10.1007/s00534-006-1153-x. PMC 2784508. PMID 17252294.
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