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Cholangitis – Quick Consult
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Last Updated / Reviewed: June 2022
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Definition
Key History
Key Physical Exam
Risk Factors for Cholangitis
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment
Complications
Acute cholangitis is a clinical syndrome characterized by fever, jaundice, and
abdominal pain that develops as a result of stasis and infection in the biliary
tract; it is typically related to biliary obstruction. The most common cause of
biliary obstruction is biliary calculi; it may also be referred to as an ascending
cholangitis. The severity of the illness may range from mild to life-threatening.
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- Charcot’s Triad: complete triad occurs anywhere from 15% to 70% of
patients
- Fever: 95%
- Abdominal pain: typically RUQ 90%
- Jaundice: 80%
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- Reynold's pentad – pain, fever, jaundice, decreased mental status,
hypotension
- History of choledocholithiasis
- Recent biliary tract manipulation
- Rigors
- History of acholic stools
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- Abdominal Pain
- Fever
- Hypotension
- Scleral icterus
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- Jaundice
- Mental status changes
- Mild hepatomegaly
- Tachycardia
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- Biliary tract manipulation
- Cholangiocarcinoma
- Choledochal/biliary cysts
- Choledocholithiasis – risk factors as gallstones
- Six F's: female, fair, forty, fat, fertile, flatus
- fair skinned people of Northern European descent, Hispanics,
Native American’s and
Pima Indians
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- Hepatolithiasis
- HIV – cryptosporidium or microsporidia infection
- Pancreatic cancer
- Parasitic infection
- Sickle cell disease
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- AIDS related cholangitis
- Asian cholangitis
- Cholecystitis
- Infected choledochal cyst
- Hepatitis
- Liver abscess
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- Mirizzi syndrome
- Pneumonia (RLL)
- Pyelonephritis
- Sclerosing cholangitis
- Septic shock
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Text / literature information and recommendations include:
- Labs:
- CBC: leukocytosis with a left shift is usually present
- CMP: liver function tests often demonstrate hyperbilirubinemia, elevated
alkaline
phosphatase, and elevated transaminases
- Blood cultures are positive in up to 50% of cases
- Imaging:
- Ultrasound (US) is a quick way to access for bile duct dilatation. 96%
accuracy
for ductal dilatation; may be performed at bedside and may image other
structures.
It is operator dependent and there is a decreased sensitivity for common bile
duct
stones. Early in the course the common bile duct may not have dilated and
gallstones
may be too small to visualize via US. A normal sonogram does not rule out acute
cholangitis.
- CT scan cholangiography is useful for imaging the biliary tree and to
identify
other pathologies. Gallstones are poorly visualized and there is a diminished
ability
to visualize the biliary tree if the serum bilirubin is elevated
- Magnetic resonance cholangiopancreatography (MRCP) is accurate for
retained
stones in the biliary system. Limitations of MRCP include the inability for
invasive
diagnostic test.
- Plain films are limited in their diagnostic value. May visualize air in
the
biliary tree, air in gallbladder wall indicating emphysematous cholecystitis may
be seen.
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- Maintain a high clinical suspicion as delay in diagnosis may result in a higher
death rate.
- Patients on corticosteroids and elderly patients may present only with hypotension.
- Suspect cholangitis in older patients who present with sepsis, hypotension or
confusion.
- Suspect cholangitis in any patient with jaundice and a fever.
- Clinical findings in cholangitis can range from mild illness to fulminant sepsis.
- It is often difficult to differentiate cholecystitis from cholangitis. Jaundice
and an elevated bilirubin are more common in cholangitis.
- Suspect cholangitis in pregnant women who present with jaundice or fever. Pregnant
women are prone to symptomatic gallstones.
- Cholelithiasis and cholangitis are uncommon in children unless they have an
underlying
biliary tree abnormality or hemolytic disorder.
- Oriental cholangiohepatitis is endemic in Southeast Asia.
- See characteristics associated with poorer outcome under Complications (below).
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Common text / literature recommendations include:
- ABCs
- IV fluid resuscitation
- Correction of electrolytes, coagulopathy if present
- Blood cultures
- Parenteral broad-spectrum antibiotics with coverage for gram-negative bacteria and
enterococcus. Anaerobic coverage can be added in sick patients or patients who have
had biliary tract instrumentation
- Establishment of urgent biliary drainage for patients with:
- Persistent abdominal pain after conservative treatment
- Hypotension after fluid resuscitation
- Fever over 39° C
- Mental confusion
- Biliary drainage can be accomplished by ERCP, direct percutaneous approach or by
surgical decompression.
- Endoscopic sphincterotomy with stone extraction and stent insertion is the current
treatment of choice for establishing biliary drainage in acute cholangitis.
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- Acute renal failure
- Liver failure
- Pyogenic liver abscess
- Bacteremia
Characteristics associated with poor outcome:
- Hypotension
- Acute renal failure
- Cirrhosis
- Inflammatory bowel disease
- High malignant strictures
- Radiologic cholangitis – post percutaneous transhepatic cholangiography
- Age older than 50 years
- Failure to respond to antibiotics and conservative therapy
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