Acute Cholangitis

Question 1

Define acute cholangitis

Answer 1

Infection of the bile duct

Question 2

Explain the aetiology / risk factors of acute cholangitis

Answer 2

Obstruction of the gallbladder or bile duct due to stones
ERCP
Tumours (e.g. pancreatic, cholangiocarcinoma)
Bile duct stricture or stenosis
Parasitic infection (e.g. ascariasis)

Question 3

Summarise the epidemiology of acute cholangitis

Answer 3

9% of patients admitted to hospital with gallstone disease will have acute cholangitis
Equal in males and females
Median age of presentation: 50-60 yrs
Racial distribution follows that of gallstone disease - fair-skinned people

Question 4

Recognise the presenting symptoms of acute cholangitis

Answer 4

Most patents present with Charcot’s Triad of symptoms:
RUQ Pain
Jaundice
Fever with rigors

This list of symptoms has been extended to include the following two symptoms, forming the Reynolds’ Pentad:
Mental confusion
Septic shock

Patients may also complain of pruritus

Question 5

Recognise the signs of acute cholangitis on physical examination

Answer 5

Fever  
RUQ tenderness 
Mild hepatomegaly 
Jaundice  
Mental status changes 
Sepsis 
Hypotension 
Tachycardia 
Peritonitis (uncommon - check for alternative diagnosis)

Question 6

Identify appropriate investigations for acute cholangitis

Answer 6

Bloods
FBC: High WCC
CRP/ESR: possibly raised
LFTs: typical pattern of obstructive jaundice (raised ALP + GGT)
U&Es: may be signs of renal dysfunction
Blood cultures: check for sepsis
Amylase: may be raised if the lower part of the common bile duct is involved

Imaging
X-ray KUB: look for stones
Abdominal ultrasound: look for stones and dilation of the common bile duct
Contrast-enhanced CT/MRI: good for diagnosing cholangitis
MRCP: may be necessary to detect non-calcified stones

Question 7

Generate a management plan for acute cholangitis

Answer 7

Resuscitation: may be required if the patient is in septic shock
Broad-spectrum antibiotics: given once blood cultures have been taken (select drugs that are effective against anaerobes and Gram-negative organisms: e.g. cefuroxime + metronidazole)
Most patients respond to antibiotics but endoscopic biliary drainage is usually required to treat the underlying obstruction

Management depends on severity:
Stage 1 (Mild)
Antimicrobial therapy
Percutaneous, endoscopic or operative intervention for non-responders (depending on aetiology)
Stage 2 (Moderate)
Early percutaneous or endoscopic drainage
Endoscopic biliary drainage is recommended
Stage 3 (Severe)
NOTE: severe cholangitis counts as including shock, conscious disturbance, acute lung injury, AKI, hepatic injury or DIC
Treatment of organ failure with ventilatory support, vasopressors etc.
Urgent percutaneous or endoscopic drainage
Definitive treatment required once the clinical picture improves

Question 8

Identify the possible complications of acute cholangitis

Answer 8

Liver abscesses  
Liver failure  
Bacteraemia  
Gram-negative sepsis  
Septic shock  
AKI  
Organ dysfunction  
Percutaneous or endoscopic drainage can lead to: Intra-abdominal or percutaneous bleeding, sepsis, fistulae and bile leakage

Question 9

Summarise the prognosis for patients with acute cholangitis

Answer 9

Mortality between 17-40%