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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


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