Ascending cholangitis

Question 1

What is ascending cholangitis?

Answer 1

Ascending cholangitis is a bacterial infection of the biliary tree.

Question 2

What are the clinical features of ascending cholangitis?

Answer 2

Charcot’s triad of (1/3 of patients):

1. Right upper quadrant pain
2. Fever
3. Jaundice

Hypotension, tachycardia and confusion are also common symptoms if the sepsis is severe.

Question 3

What are the causes of ascending cholangitis?

Answer 3

Biliary calculi (stones) – 50%

Benign biliary stricture – 20%. These can be congenital, post-infectious, or inflammatory.

Malignancy – 10-20%. These can be due to tumour in the gallbladder, bile duct, ampulla, duodenum, pancreas.

Question 4

What investigations would you do for cholangitis?

Answer 4

A basic blood panel will show raised LFTs with raised inflammatory markers (White cells and CRP).

Once an aetiology has been determined, ERCP can be used as a therapeutic intervention.

Question 5

How would you manage ascending cholangitis?

Answer 5

Resuscitation including intravenous fluids and antibiotics (according to local guidelines). Critical care may be required depending on the presence or severity of shock and organ failure

Biliary drainage may be required

Endoscopic drainage – ERCP (Endoscopic retrograde cholangiopancreatography). This may involve stent placement for strictures.

Percutaneous drainage – PTC (Percutaneous transhepatic cholangiography)
Surgical drainage