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
Causes of cholangitis
Appearance
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
Tests
Blood investigations
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
Prognosis
The mortality rate is about 10%. A poor prognosis is associated with:
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%.