Acute Cholangitis

Question 1

Define acute cholangitis

Answer 1

Acute cholangitis = acute bile tree/duct infection

Ascending cholangitis

Question 2

Explain the aetiology of acute cholangitis

Answer 2

Stasis or obstruction: (Partial obstruction has a higher rate of infection than complete)

Choledocholithiasis = gallstones in the common bile duct
10-15% of patients

Iatrogenic – ERCP and surgical injury
Sclerosing cholangitis (24%)

Tumours:
Pancreatic cancer
Cholangiocarcinoma
Ampullary cancer

AIDS cholangiopathy

Parasites

Question 3

Explain the risk factors for acute cholangitis

Answer 3

Age >50

Cholelithiasis = gallstones

Benign/malignant stricture

Post-procedure injury

History of sclerosing cholangitis (Leads to stricture and obstruction)

HIV infection

Question 4

What is the epidemiology of acute cholangitis?

Answer 4

Uncommon – only 1% of patients with gallstones
Equal male:female ratio
Usually present aged 50-60 y/o
1-3% present after ERCP
Usually due to inadequate biliary drainage
Increased risk if dye is injected retrograde

Recurrent oriental pyogenic cholangitis more common in Eastern world

Question 5

What are the presenting symptoms of acute cholangitis?

Answer 5

RUQ abdominal pain (constant)

Pruritus (itching without a rash)

Question 6

What are the signs of acute cholangitis on physical examination?

Answer 6

Mild hepatomegaly
Jaundice (60%)
Rigors
Fever (90%)
Acholic (pale) stools 

If septic:
Mental changes (confusion)
Hypotension

Charcot’s triad - RUQ pain, Jaundice, Fever – with or without rigors

Reynold’s pentad = Charcot’s triad + mental status changes + sepsis (hypotension)

Question 7

What investigations should be done for acute cholangitis?

Answer 7

First line
Bloods - FBC
Severe = raised urea, creatinine
LFTs – raised ALT, AST, ALP, bilirubin
CRP – raised

ABG

• Low bicarbonate with raised anion gap
• Metabolic acidosis

Blood cultures
- Usually gram-negative bacteria

Ultrasound
-With RUQ as presenting complaint

ERCP
- With biliary disease history, indwelling biliary prosthesis or risk factors

Other investigations
Abdominal CT with IV contrast
Bile duct dilation
MRCP - See mass impinging on biliary tree
o	PTC
o	Surgery

Question 8

What treatments are given for acute cholangitis?

Answer 8

IV antibiotics
Intensive medical management
Non-surgical biliary decompression – Lithotripsy
ERCP
Surgical biliary decompression
Opioids

Question 9

What are possible complications of acute cholangitis?

Answer 9

Acute pancreatitis
Hepatic abscess
Renal failure
Cardiac arrhythmia

Question 10

What is the prognosis of acute cholangitis?

Answer 10

Adequate biliary drainage quickly obtained has good outcomes = Rapid clinical, haemodynamic and systemic inflammatory improvement

Delayed decompression, underlying medical conditions, and emergency surgery have worse outcomes

Predictive factors: Hyperbilirubinaemia, high fever, leucocytosis, elderly