Cholangitis

Definition: Acute bacterial infection of the bile ducts resulting from common bile duct obstruction. Also called ascending cholangitis

Hepatobiliary Tract Anatomy

Pathophysiology


The common bile duct develops an obstruction

Obstruction may be incomplete (more common) or complete

Causes: Gallstones (most common), malignancy, benign stricture, iatrogenic (i.e. ERCP)

Elevated intraluminal pressure in the gallbladder leads to translocation of bacteria

Bacteria may gain access via lymphatics, portal venous blood or retrograde from the duodenum

Common pathogens: E. coli, Klebsiella, Streptococcus, Enterobacter, Pseudomonas Other causes: HIV/AIDS cholangiopathy, parasitic infections (Ascaris lumbricoides)

Presentation

ÚCharcot’s Triad: Fever, RUQ pain and jaundice (neither sensitive nor specific)
Symptoms

Fever/chills

Nausea/vomiting

Abdominal pain

Physical Exam

RUQ tenderness to palpation

Peritoneal signs are variable

Jaundice

Frank sepsis (fever, tachycardia, hypotension, tachypnea) is a common presentation

Reynold’s Pentad: Charcot’s triad + sepsis and AMS

Acute Cholangitis Infographic (mediconet.blogspot.com)

Acute Cholangitis Infographic (mediconet.blogspot.com)

Diagnostics
Cholangitis is a clinical diagnosis. There are no diagnostic tests that absolutely clinches or rules out the diagnosis.

Laboratory Tests

Lab tests are generally neither sensitive nor specific for ruling in or ruling out cholangitis. Below are common findings

WBCs – usually elevated but may be depressed in severe infection

Hepatic panel

Elevated aminotransferases (i.e ALT/AST)

Elevated alkaline phosphatase

Hyperbilirubinemia

Lipase – useful to evaluate for concomitant pancreatitis

Blood gas may be useful in patients who appear septic to record lactate level

Blood cultures

Imaging

Imaging is helpful in supporting the diagnosis and aids in identifying the cause. Many patients will have concomitant acute cholecystitis that will be identified on imaging

Ultrasound (US) Ultrasound with Dilated Common Bile Duct (CBD)

Ultrasound with Dilated Common Bile Duct (CBD)
Common findings

Intrahepatic Biliary Duct Dilation from Core EM on Vimeo.

Intrahepatic biliary ductal dilation (see video below)

Thickening of the bile duct walls

Obstructing gallstones

Concomitant cholecystitis findings

4 sonographic signs of cholecystitis: Gallstones, gallbladder wall thickening >3mm, pericholecystic fluid, sonographic murphy’s

Gallstones + sonographic murphy’s

Highly sensitive (87-95%) and specific (82%) when examining the gallbladder and biliary ducts (Carmody 2011, Summers 2010)

Not highly sensitive for diagnosing choledocholithiasis: can miss distal CBD stones

Useful to distinguish between intrahepatic and extrahepatic obstruction

CT Scan

Classic finding: non-homogenous liver enhancement during arterial phase

Can identify dilated intra- and extrahepatic ducts

Gallstones are poorly visualized

Findings non-specific

Can identify other pathologies or complications of cholangitis (perforation, abscess)

Other Diagnostic Imaging

Nuclear scintigraphy: may be more sensitive than US in identifying early obstruction

Useful when ultrasound results are equivocal and the diagnosis is suspected

Cannot visualize the biliary tree with complete obstruction

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Procedure is both diagnostic + potentially therapeutic

Allows removal of obstructing stone, biopsy of mass, culture of bile and decompression or stent placement
Immediate Management:

Basics:

ABCs, IV, Cardiac Monitor

Unstable patients due to sepsis or septic shock should be aggressively resuscitated per general sepsis/septic shock algorithms (IV fluids, airway management as necessary, vasoactive substances etc.)

Directed Management

Broad spectrum antibiotics

Antibiotics should cover gram positive, anaerobic gram negative aerobic andenteric organisms (see above)

Common regimens

Piperacillin/tazobactam (Zosyn®)

Imipenem/Meropenem

Ampicillin/sulbactam (Unasyn®) + metronidazole

Correct electrolyte abnormalities and coagulopathies if present

Biliary tract decompression

Percutaneous drainage via interventional radiology

ERCP via gastroenterology

Surgical drainage

Disposition:
All patients with cholangitis will require admission and many will require a high-resource setting (ICU or step down unit)

Take Home Points
Cholangitis is a potentially life-threatening (mortality 5-10%, acute bacterial infection of the bile ducts

Diagnosis is based on clinical findings and while imaging can be supportive, it is frequently non-diagnostic

A normal ultrasound does not rule out acute cholangitis

Treatment focuses on supportive care, broad spectrum antibiotics and consultation with a provider that can provide biliary tract decompression (IR, gastroenterology or general surgery)

Read More

Radiopaedia: Acute cholangitis
References

Oyama LC: Disorders of the liver and biliary tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 90: p 1186-1205.

Summers S et al. A Prospective Evaluation of Emergency Department Bedside Ultrasonography for the Detection of Acute Cholecystitis. Ann Emerg Med. 2010;56(2): 114-122. PMID: 20138397

Carmody KA, Moore CL, Feller-Kopman D, (eds). Handbook of Critical Care & Emergency Ultrasound. New York, NY: McGraw Hill, 2011, pp.123-144.

Richter J et al. Ultrasound in Tropical and Parasitic Diseases. Lancet 2003; 362:900-902. PMID: 13678978

 Anand Swaminathan, MD, MPH

@emswami
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by Anand Swaminathan, MD, MPH

Anand “Swami” Swaminathan is an assistant professor of Emergency Medicine in the Ronald O. Perelman Emergency Department and assistant residency director of the NYU/Bellevue Emergency Medicine residency program. His interests are in resuscitation medicine, resident education and cutting the knowledge translation window. Swami is an active contributor and supporter of innovations in medicine, particularly Free Open Access Medical Education (FOAM). He is a contributor to a number of sites including ALiEM, LITFL, ERCast, EMCrit, TheSGEM, REBEL EM and EMDocs.net. Swami is also the assistant course director of the Teaching Course and faculty for EM: RAP and Essentials of Emergency Medicine.

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