Cholangitis

• Glenn G. Fort, M.D., M.P.H.

 Basic Information

Definition

Cholangitis refers to an inflammation and/or infection of the hepatic and common bile ducts associated with obstruction of the common bile duct.

Synonyms

1. Biliary sepsis

2. Ascending cholangitis

3. Suppurative cholangitis

ICD-10CM CODES
K83.0	Cholangitis

Epidemiology & Demographics

Incidence (In U.S.)

Complicates approximately 1% of cases of cholelithiasis

Peak Incidence

Seventh decade

Prevalence (In U.S.)

2 cases/1000 hospital admissions

Predominant Sex

1. •

   Females, for cholangitis secondary to gallstones

2. •

   Males, for cholangitis secondary to malignant obstruction and HIV infection

Predominant Age

Seventh decade and older; unusual <50 yr of age

Physical Findings & Clinical Presentation

1. •

   Usually acute onset of fever, abdominal pain (RUQ), and jaundice (Charcot’s triad)

2. •

   All signs and symptoms in only 50% to 85% of patients

3. •

   Often, dark coloration of the urine resulting from bilirubinuria

4. •

   Complications:

   1. 1.

      Bacteremia (50%) and septic shock

   2. 2.

      Hepatic abscess and pancreatitis

Etiology

Obstruction of the common bile duct causing rapid proliferation of bacteria in the biliary tree

1. •

   Most common cause of common bile duct obstruction: stones, usually migrated from the gallbladder

2. •

   Other causes: prior biliary tract surgery with secondary stenosis, tumor (usually arising from the pancreas or biliary tree), and parasitic infections from Ascaris lumbricoides or Fasciola hepatica

3. •

   Iatrogenic after contamination of an obstructed biliary tree by endoscopic retrograde cholangiopancreatoscopy (ERCP) or percutaneous transhepatic cholangiography (PTC)

4. •

   Primary sclerosing cholangitis (PSC)

5. •

   HIV-associated sclerosing cholangitis: associated with infection by CMV, Cryptosporidium, Microsporida, and Mycobacterium avium complex

Diagnosis

Differential Diagnosis

1. •

   Biliary colic

2. •

   Acute cholecystitis

3. •

   Liver abscess

4. •

   Peptic ulcer disease (PUD)

5. •

   Pancreatitis

6. •

   Intestinal obstruction

7. •

   Right kidney stone

8. •

   Hepatitis

9. •

   Pyelonephritis

Workup

1. •

   Blood cultures

2. •

   CBC

3. •

   Liver function tests

Laboratory Tests

1. •

   Usually, elevated WBC count with a predominance of polymorphonuclear forms

2. •

   Elevated alkaline phosphatase and bilirubin in chronic obstruction

3. •

   Elevated transaminases in acute obstruction

4. •

   Positive blood cultures in 50% of cases, typically with enteric gram-negative aerobes (e.g., Escherichia coli, Klebsiella pneumoniae), enterococci, or anaerobes

Imaging Studies

1. •

   Ultrasound:

   1. 1.

      Allows visualization of the gallbladder and bile ducts to differentiate extrahepatic obstruction from intrahepatic cholestasis

   2. 2.

      Insensitive but specific for visualization of common duct stones

2. •

   CT scan:

   1. 1.

      Less accurate for gallstones

   2. 2.

      More sensitive than ultrasound for visualization of the distal part of the common bile duct

   3. 3.

      Also allows better definition of neoplasm

3. •

   ERCP:

   1. 1.

      Confirms obstruction and its level

   2. 2.

      Allows collection of specimens for culture and cytology

   3. 3.

      Indicated for diagnosis if ultrasound and CT scan are inconclusive

   4. 4.

      May be indicated in therapy (see “Treatment”)

Treatment

Nonpharmacologic Therapy

Biliary decompression

1. •

   May be urgent in severely ill patients or those unresponsive to medical therapy within 12 to 24 hr

2. •

   May also be performed semielectively in patients who respond

3. •

   Options:

   1. 1.

      ERCP with or without sphincterotomy or placement of a draining stent.

   2. 2.

      Percutaneous transhepatic biliary drainage for the acutely ill patient who is a poor surgical candidate.

   3. 3.

      Recently, endoscopic ultrasound–guided biliary drainage has been proven as an alternative to percutaneous transhepatic biliary drainage in specialized centers when ERCP fails or is not available.

   4. 4.

      Surgical exploration of the common bile duct.

Acute General Rx

1. •

   Nothing by mouth

2. •

   Intravenous hydration

3. •

   Broad-spectrum antibiotics directed at gram-negative enteric organisms, anaerobes, and enterococcus such as carbapenems (meropenem: 1 g q8h or imipenem: 500 mg IV q6h if life threatening), piperacillin/tazobactam: 3.375 or 4.5 g IV q6h, or ampicillin-sulbactam, or ticarcillin-clavulanate; if infection is nosocomial, post-ERCP, or the patient is in shock, broaden antibiotic coverage.

Chronic Rx

Repeated decompression may be necessary, particularly when obstruction is related to neoplasm.

Disposition

Excellent prognosis if obstruction is amenable to definitive surgical therapy; otherwise relapses are common.

Referral

1. •

   To biliary endoscopist if obstruction is from stones or a stent needs to be placed

2. •

   To interventional radiologist if external drainage is necessary

3. •

   To a general surgeon in all other cases

4. •

   To an infectious disease specialist if blood cultures are positive or the patient is in shock or otherwise severely ill

Pearls & Considerations

1. •

   Cholangitis is a life-threatening form of intra-abdominal sepsis, though it may appear to be rather innocuous at its onset.

2. •

   Antibiotics alone will not resolve cholangitis in the presence of biliary obstruction, because high intrabiliary pressures prevent antibiotic delivery. Decompression and drainage of the biliary tract to alleviate the obstruction with antimicrobial therapy is the therapy of choice.

Suggested Reading

• P. Mosler: Diagnosis and management of acute cholangitis. Curr Gastroenterol Rep. 13 (2):166–172 2011 21207254