Definition

Key History

Key Physical Exam

Risk Factors for Cholangitis

Differential Diagnosis

Diagnostic Testing

• Labs:
• CBC: Leukocytosis with a left shift is usually present.
• CMP: Liver function tests often demonstrate hyperbilirubinemia, elevated alkaline phosphatase, and elevated transaminases.
• C-reactive protein and Procalcitonin can help assess the severity of the infection.
• Blood cultures are positive in up to 50% of cases.
• Imaging:
• Ultrasound (US) is a quick way to assess for bile duct dilatation. 96% accuracy for ductal dilatation; can be performed at bedside and can 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 testing.
• Plain films are limited in their diagnostic value. May visualize air in the biliary tree, air in gallbladder wall indicating emphysematous, and cholecystitis may be seen.

Clinical Risk and Safety Pearls

• 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).

Treatment

• 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 (102.2°F)
  • Mental confusion
• Biliary drainage can be accomplished by Endoscopic retrograde cholangiopancreatography (ERCP), direct percutaneous approach, or surgical decompression.
• Endoscopic sphincterotomy with stone extraction and stent insertion is the current treatment of choice for establishing biliary drainage in acute cholangitis.

Complications

• Acute renal failure
• Liver failure
• Pyogenic liver abscess
• Bacteremia

• 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