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Cholangitis

 

Definition of cholangitis

  • Inflammation and/or infection of the biliary tree
  • Often referred to as ‘biliary sepsis’

 

Epidemiology of cholangitis

  • Rare but can be 1-2% post ERCP

 

Causes of cholangitis

  • Obstruction of biliary tree secondary to gallstones  (including Mirizzi’s syndrome, gallstone-related  oedema compressing biliary tree as opposed to gallstones themselves)
    • Commonest cause
  • Infection post-ERCP
  • Invasion by tumour
    • Pancreatic, cholangiocarcinoma, hepatocellular carcinoma, metastases
  • Roundworm or liver fluke infection (common overseas)
  • HIV cholangiopathy

 

Presentations of cholangitis

The following make up the classical ‘Charcot’s triad’

  • Jaundice
  • Fever
  • RUQ pain – severe
    • Shock (due to sepsis) and confusion added to Charcot’s triad = Reynold’s pentad
  • Jaundice may not always be present, especially if a patient already has a biliary stent in situ
  • PMHx
    • Gallstones
    • Cholecystitis
    • HIV
  • Peritonism is uncommon and suggests alternative cause, e.g. appendix or ruptured gall bladder

 

Differential diagnosis of cholangitis

  • Cholecystitis
  • Other causes of acute jaundice
  • CBD gallstone causing obstructive jaundice

 

 

Initial management of cholangitis

  • Blood tests:
    • Full blood count
    • Urea and electrolytes
    • Clotting
    • Amylase
    • Inflammatory markers
  • Blood cultures
    • Usually gram-negative: E.coli, Klebsiella, Enterobacter
  • Imaging:
    • AXR – may show ileus or air in biliary tree (e.g. after ERCP; gas-producing organisms; cholecystenteric-fistula)
    • USS – gallstones or dilated ducts
    • CT abdomen
  • Prompt IV fluid resuscitation
  • Prompt IV antibiotics
    • Broad spectrum with gram-negative cover
    • Often IV Tazocin 4.5g three times daily or IV Meropenem 1g three times daily but check local guidelines or guided by culture sensitivities
  • Catheterisation for fluid balance
  • These patients are often sick and may need HDU or ITU management

 

Further management of cholangitis

  • MRCP (magnetic retrograde cholangiopancreatography)
  • ERCP (endoscopic retrograde cholangiopancreatography)
    • This can be diagnostic and therapeutic as stones can be removed and a sphincterotomy performed at the Sphincter of Oddi to prevent future episodes
    • There is, however, a significant associated morbidity and mortality
      • Pancreatitis (up to 5%)
      • Cholangitis (up to 3.5%)
      • Perforation (up to 0.6%)
      • Death (0.2%)
  • Biliary scintography
    • Radio-active substance secreted in bile
    • Can demonstrate an obstruction if diagnosis unsure
  • Cholecystectomy
    • All patients with an episode of biliary sepsis secondary to gallstones should be referred to the surgeons for consideration of an elective cholecystectomy once recovered.

 

Complications of cholangitis

  • Septic shock and death
  • Intra-abdominal collection

 

Prognosis of cholangitis

  • Acute cholangitis has a high mortality (7-40%),
  • Higher mortality in patients with co-morbidities, e.g. elderly, renal failure, cirrhosis, metastatic disease, failure to respond to antibiotics

 

Click here for medical student OSCE and PACES questions about Cholangitis

Common Cholangitis exam questions for medical students, finals, OSCEs and MRCP PACES

 

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Perfect revision for medical students, finals, OSCEs and MRCP PACES