Cholangitis overview
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
Cholangitis is a clinically defined syndrome of fever, right upper quadrant pain and jaundice caused by infection of bile and inflammation of the biliary tree, usually due to obstruction and stasis.
Historical Perspective
Cholangitis was first described as a life-threatening disorder in 1877 by Charcot. In 1955, Reynolds and Dargan recognized that septic shock and mental status changes portended a poor outcome. (Reynolds’s Pentad). [1] [2] [3] [4]
Causes
Cholangitis is usually caused by a bacterial infection, which can occur when the duct is blocked by something, such as a gallstone or tumor. The infection causing this condition may also spread to the liver.
Epidemiology and Demographics
Parasites are commonly associated with cholangitis outside of the United States. Parasites associated with cholangitis include the Ascaris, Opisthorchis, Clonorchis, Fasciola and Echinococcus. Ascaris is thought to be the etiologic agent of recurrent pyogenic cholangitis (Oriental cholangiohepatitis) found in Hong Kong, Southeast Asia, Columbia, Italy and South Africa. As they migrate to the biliary tree, they bring gut flora with them predisposing to bacterial infection. Dying worms lead to inflammation, granulomatous scarring and fibrosis which may lead to biliary cirrhosis. Opisthorchis and Clonorchis are transmitted by raw fish in Asia, Europe and Siberia and “frequently” lead to the development of cholangiocarcinoma. Fasciola is transmitted by colonized watercress and does not predispose to cholangiocarcinoma.
Diagnosis
History and Symptoms
The classical clinical manifestation of Cholangitis is described by Charcot's triad and includes fever, right upper quadrant pain, and jaundice. In suppurative cholangitis hypotension, and confusion can occur. The pentad of presentation is then called as Reynold's pentad. Reynold's pentad is associated with significant morbidity, and mortality.
Laboratory Findings
Laboratory tests provide useful clues in the diagnosis of cholangitis. Some commonly conducted tests are complete blood count, basic metabolic panel, liver function tests, blood culture, and other body fluid culture.
CT
CT has a higher sensitivity (63%) and is better to localize the site of obstruction.
Diagnostic Criteria
The diagnostic criteria for acute cholangitis according to Tokyo guidelines is as follows.[5]
| Clinical Manifestations | |
|---|---|
| Systemic inflammation | Fever and/or shaking chills Laboratory data evidence of inflammatory response |
| Cholestasis | Jaundice Laboratory data evidence of abnormal liver function tests |
| Imaging | 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) |
Suspected diagnosis: One item in systemic inflammation with one item in either cholestasis or imaging.
Definite diagnosis: One item in systemic inflammation, one item in cholestasis and one item in imaging.
Thresholds:
- Fever: baseline temperature >38℃
- Evidence of inflammatory response
- WBC (×1000/μl) <4, or >10
- CRP (mg/dl) ≥1
- Jaundice: 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
Severity Assessment Criteria
The severity assessment criteria for acute cholangitis according to Tokyo guidelines is as follows.[5]
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
Primary Prevention
Treatment of gallstones, tumors, and infestations of parasites may reduce the risk for some people. A metal or plastic stents within the bile system may be needed to prevent recurrence.
References
- ↑ Kadakia S. Biliary Tract Emergencies. Med Clin North Amer. 1993, 77(5) 1015-1036. PMID 8371614
- ↑ Carpenter H. Bacterial and Parasitic Cholangitis. May Clin Proc. 1998, 73:473-478. PMID 9581592
- ↑ Leese T, Neoptolemos JP, Baker AR. Management of acute cholangitis and the impact of endoscopic sphincterotomy. Br J Surg. 1986, 73:988. PMID 3790964
- ↑ Lai ECS, Mok FPT, Tan ESY. Endoscopic biliary drainage for severe acute cholangitis. NEJM 1992, 326:1582-6. PMID 1584258
- ↑ 5.0 5.1 Mayumi, T.; Someya, K.; Ootubo, H.; Takama, T.; Kido, T.; Kamezaki, F.; Yoshida, M.; Takada, T. (2013). "Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis". J UOEH. 35 (4): 249–57. PMID 24334691. Unknown parameter
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