Cholangitis

Question 1

Define cholangitis

Answer 1

Infection and inflammation of the biliary tree, most commonly caused by obstruction

Question 2

Aetiology of cholangitis

Answer 2

Ascending cholangitis is a bacterial infection (typically E. coli) of the biliary tree. The most common predisposing factor is gallstones.

• Cholelithiasis -> choledocholithiasis and biliary obstruction
• Iatrogenic biliary duct injury (commonly via surgical injury during cholecystectomy) -> benign strictures
• 1-3% of patients develop cholangitis after ERCP
• Sclerosing cholangitis (primary and secondary) - 24% of cases
• Chronic pancreatitis + stenosis and stricture of the distal common bile duct
• Radiation-induced biliary injury
• Biliary injury as a complication of systemic chemotherapy
  Obstruction of the common bile duct -> liver pathology

Question 3

Symptoms of cholangitis

Answer 3

Charcot’s triad
- Right upper quadrant pai
- Jaundice
- Fever

• Right upper quadrant tenderness
• Pruritus
• Mental status changes
• Pale stools

Reynold’s = +hypotension, confusion

Question 4

Signs of cholangitis on examination

Answer 4

General/obs:
- Hypotension
- Fever
- Jaundice
- Mental status changes

Abdo:
- Right upper quadrant tenderness

PR:
- Pale stools

Question 5

Investigations for cholangitis

Answer 5

LFTs: hyperbilirubinaemia, raised ALT/AST, ALP
FBC: raised WCC, thrombocytopenia
ABG/VBG: metabolic acidosis, raised lactate
CRP: raised
U&Es: K+/Mg reduced
Renal screen: severe → U and Cr raised
Blood cultures: ?bacteraemia
Clotting: raised PTT

Abdo US: ?dilated bile ducts, common bile duct stones
ERCP: stone/obstruction seen
MRCP: mass impinging on biliary tree, stricture, and/or choledocholithiasis (If ERCP and USS cannot confirm presence of gallstones)

Question 6

Management for cholangitis

Answer 6

Sepsis 6
1. Blood cultures
2. IV Abx e.g. piperacillin IV
3. IV fluids + correct electrolyte imbalances + clotting abnormalities
4. urine output, oxygen, lactate
+ Analgesia

→ biliary decompression with ERCP + drainage stent (24-48hrs)
- Or percutaneous trans-hepatic cholangiography
- Consider endoscopic lithotripsy
- Surgery: choledochotomy with T tube placement or cholecystectomy with bile duct exploration

Ongoing, non-emergency - elective surgery cholecystectomy if cholelithiasis is present

Question 7

Prognosis of cholangitis

Answer 7

Rapid improvement once adequate biliary drainage is achieved, with improvement in haemodynamic parameters with significant inflammatory response parameters
Patients with significant underlying medical conditions + those who have delay in decompression have poorer prognosis
Poor prognosis: hyperbilirubinaemia | high fever | leucocytosis | older age

Question 8

Complications of cholangitis

Answer 8

Acute pancreatitis
- Via obstruction of the pancreatic duct or the common channel joining common bile duct and pancreatic duct
- Also complication of ERCP
Inadequate biliary drainage following endoscopy, radiology or surgery
Hepatic abscess