Cholangitis

Acute obstructive cholangitis is a syndrome consisting of lethargy or mental confusion and shock, as well as fever, jaundice, and abdominal pain caused by biliary obstruction.

Acute cholecystitis is an acute inflammatory disease of the gallbladder, often caused by gallstones; however, many factors (eg, ischaemia, motility disorders, chemical injury, infections by micro-organism, protozoon and parasites, collagen disease, and allergic reactions) are also involved.

The term hepatic fever refers to Intermittent fever accompanied by chills, right upper quadrant abdominal pain, and jaundice.

Bile is normally sterile; however, if the common bile duct (CBD) is obstructed the flow of bile is reduced (biliary stasis) and infection can occur. Infection can also flow in a retrograde direction up the CBD as a result of acute cholecystitis or instrumentation such as endoscopic retrograde cholangiopancreatography (ERCP).

It is important to note that Primary Sclerosing Cholangitis is an aetiologically unrelated idiopathic condition which is dealt with in a separate article.

Prevalence of Cholangitis

1. The racial distribution pattern follows to some extent the races in which there is a high prevalence of gallstones – ie fair-skinned people of Northern European descent, Hispanics, native Americans and Pima Indians..
2. The male to female ratio is equal.
3. Up to 9% of patients admitted to hospital with gallstone disease have acute cholangitis
4. Malignant disease (bile duct tumours, gallbladder tumours, ampullary tumours, pancreatic tumours and duodenal tumours) accounts for 10-30% of cases with acute cholangitis.
5. The median age of presentation is 50-60.
6. 0.5-2.4% of patients develop cholangitis after ERCP.

Causes of cholangitis

1. Bile duct stricture or stenosis
2. Obstruction of the gallbladder or bile duct due to stones
3. ADS cholangiopath
4. Parasitic infection – roundworm, liver fluke
5. Choledochocele (cyst or diverticulum of the CBD)
6. Tumours – pancreatic cancer, cholangiocarcinoma, ampullary cancer, porta hepatis tumours or metastasis
7. ERCP

Appearance

1. 50-70% of patients present with classic Charcot’s triad of jaundice, fever and right upper quadrant pain.
2. In elderly patients, the abdominal pain may be poorly localised.
3. Physical signs may include fever, right upper quadrant tenderness, jaundice, mental status changes, hypotension and tachycardia. Peritonism is an unusual sign and should stimulate the search for an alternative diagnosis.
4. Some patients present with several attacks, usually in association with untreated biliary stones (recurrent pyogenic cholangitis).
5. A history of gallstones, CBD stones, recent cholecystectomy, ERCP or other invasive procedures, HIV or AIDS may assist the diagnosis.
6. The patient may also report alcoholic (putty-coloured) stools and pruritis.
7. Acute cholangitis is graded in severity from grade I (mild), grade II (moderate) and grade III (severe). Severe acute cholangitis is acute cholangitis associated with at least one of cardiovascular, neurological, respiratory, renal, hepatic and/or haematological dysfunction.
8. 10-20% of patients also present with the additional features of Low blood pressure (Hypotension) due to septic shock and mental confusion – the Reynolds’ pentad.

Diagnostic criteria for acute cholangitis

1.Cholestasis
Jaundice Laboratory data: abnormal LFTs; increased serum ALP, AST, ALT and gamma-GT levels

2. Imaging
Biliary dilatation Evidence of the aetiology on imaging (eg, stricture, stone, stent)

3. Systemic inflammation:
Fever and/or shaking chills
Laboratory data: evidence of inflammatory response – eg, abnormal white blood cell count, raised CRP

Other conditions causing similar condition

1. Liver failure
2. Pancreatitis
3. Diverticu;ar disease
4. Appendicitis
5. Pyelonephritis
6. Gallstone with Cholecystitis
7. Hepetitia Ex – Viral/drug induced
8. Mesentric Ischemia
9. Perforation
10. Cirrhosis
11. Liver Abscess

Tests
Blood investigations

1. LFTs: typically show pattern of obstructive jaundice
2. Kidney function tests and electrolytes: associated renal dysfunction
3. FBC: the white cell count is usually raised.
4. If bile fluid is available (eg, biliary drainage through intervention has occurred), a sample should be sent for culture.
5. nflammatory markers: ESR and CRP may be raised.
6. Blood culture
7. Amylase may be raised and then often indicates involvement of the lower part of the common bile duct.

Imaging

When acute cholangitis is suspected, diagnostic assessment includes abdominal X-ray (kidneys, ureters and bladder (KUB)) and abdominal ultrasound. These two may be followed by CT scan, MRCP (magnetic resonance cholangiopancreatography) when needed.

Controlling Cholangitis effectively

The initial management consists of fluid resuscitation, correction of coagulopathy, and administration of broad-spectrum antibiotics.
1. Resucitation maybe required for patients with sevre sepsis (Sceptic Shock) and due attention should be given to oxygenation and correction of fluid and electrolyte imbalance. Vital signs should be monitored.

2.Parenteral antibiotics should be administered once blood cultures have been taken. The drugs selected should be effective against anaerobes and Gram-negative organisms.

Most patients with acute cholangitis respond to antibiotic therapy, but endoscopic biliary drainage is ultimately required to treat the underlying obstruction.

The type and timing of biliary drainage is based on the severity of the clinical presentation, and the availability and feasibility of drainage techniques.

Endoscopic biliary drainage – ERCP (Endoscopic Retrograde cholangiopancreatography) is recommended for acute cholangitis. Percutaneous transhepatic biliary cholangitis drainage may be considered as an alternative when endoscopic biliary drainage is difficult.

Open surgical drainage is rarely performed.

Defenitve surgery is then planned after stabilising and resucitating the patient.

Recurrent pyogenic cholangitis may require more radical surgery such as liver resection.

Complexities

1. Severe acute cholangitis may cause septic shock, acute kidney injury and cardiovascular, neurological, respiratory, renal, hepatic and/or haematological dysfunction.
2. Patients treated with percutaneous or endoscopic drainage can develop intra-abdominal or percutaneous bleeding, sepsis, fistulae and bile leakage
3. Patients with severe sepsis can develop liver abscesses and liver failure, bacteraemia and Gram-negative sepsis.

Prognosis
The mortality rate is about 10%. A poor prognosis is associated with:

1. High malignant strictures; cholangitis following percutaneous transhepatic cholangiography Hypotension, acute kidney injury, liver abscess
2. Cirrhosis, inflammatory bowel disease
3. Age older than 50 years, female gender
4. A white cell count on admission of ≥20 x 109/L and total bilirubin of ≥880 μmol/L
5. Failure to respond to antibiotics and conservative therapy

CONCLUSION
Cholangitis is a medical emergency which most of time needs Intensive Care treatment (ICU) to start with. Infection is controlled with combination of high dose antibiotics, drainage of biliary system and fluid resucicitation. Course of the treatment will change depending on pateints general health, co-mobidities and if any other organs are affected. Defenitive surgical intervention will be needed depending on the primary cause. Mortality (Death) is very high around 10%.