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Patients have fever, jaundice, and right upper quadrant pain (Charcot's triad). This is a serious potentially life-threatening condition of the bile ducts

About

• Cholangitis is a serious life-threatening bacterial Infection of the Biliary tree
• Cholangitis is an inflammation of the bile duct system.
• Look for a stone in the CBD or some physical cause or obstruction

Aetiology

• The most common cause, where stones block the bile duct, leading to infection.
• Biliary Strictures which can occur after surgery or due to chronic inflammation.
• Tumours: cholangiocarcinoma or pancreatic cancer, can obstruct the bile ducts.
• Parasites: parasitic infections like liver flukes can cause bile duct obstruction.

Microbiology

• Escherichia coli, Klebsiella spp., Pseudomonal species, Enterobacter spp.
• Acinetobacter spp. of Gram-negative bacteria, enterococcus, streptococcus
• Staphylococcus Gram positive bacteria

Types

• Primary sclerosing (PSC)
• Secondary (acute) cholangitis (subject here)
• IgG4-associated cholangitis (IAC)

Causes

• Gallstones
• Benign and malignant strictures
• Primary sclerosing cholangitis
• Chronic pancreatitis
• HIV related cholangiopathy

Clinical

• "Charcot's triad" - Jaundice, RUQ pain, Fever/Rigors
• "Reynolds' pentad" - Jaundice, RUQ pain, Fever/Rigors + Confusion and shock
• Biliary obstruction - dark urine and pale stool
• Hypotension: Low blood pressure, indicating septic shock.
• Altered Mental Status: Confusion or lethargy, which may indicate sepsis.

Diagnostic Criteria

• Clinical features
  • 1. Previous biliary disorder
  • 2. Fever and/or chills
  • 3. Jaundice
  • 4. Abdominal pain
• Laboratory features
  • 5. Presence of inflammation indicators (High WCC and C-reactive protein)
  • 6. Elevated liver enzymes
• Imaging findings
  • 7. Biliary dilatation, other abnormalities suggesting hepatobiliary disorder
• Suspected diagnosis Two or more items of clinical features
• Definite diagnosis Either Charcot's triad (2+3+4) or two items in the clinical features along with both items in the laboratory and imaging findings

Investigations

• FBC: Raised WCC and CRP
• LFT'S usually Raised ALP and Raised GGT Raised Bilirubin
• Blood Cultures: Can identify the causative bacteria, particularly in septic patients.
• Liver USS to look for stones and CBD dilatation
• Abdominal CT can be useful and can help identify complications like abscesses.
• ERCP allows imaging and identification and allows stenting and/or release of stone by sphincterotomy possibly. It is the gold standard for diagnosis of cholangitis

Complications

• Sepsis, hypotension, multi-organ failure, and mental status changes.
• Empyema of the gallbladder: fills with infected fluid, eventually leading to pus
• Liver Abscess: Pockets of infection within the liver can develop due to untreated cholangitis.
• Acute Kidney Injury: Often due to sepsis or dehydration.
• Biliary Cirrhosis: Long-standing obstruction and inflammation can lead to scarring of the liver.

Management

• IV fluids and resuscitation and basic ABC. IV Antibiotics
• ERCP and Drainage of the biliary tree is the most critical step in management if obstructed.
• IV antibiotics - various regimens e.g. Cephalosporin/Metronidazole or Amoxicillin and Gentamicin
• ERCP usually with a sphincterotomy to allow a stone to pass and provide biliary drainage. Important to correct any coagulopathy before a sphincterotomy.
• If there is a malignant lesion or stricture a stent can be placed by ERCP or sphincterotomy performed
• Consider cholecystectomy at 6-12 weeks for gallbladder stones and is commonly done laparoscopically nowadays

References

• Cholangitis: Diagnosis, Treatment and Prognosis