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Acute cholangitis

Last updated: July 15, 2020

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Acute cholangitis (ascending cholangitis) refers to a bacterial infection of the biliary tract, typically secondary to biliary obstruction and stasis (e.g., due to choledocholithiasis, biliary stricture). Charcot triad, which consists of RUQ pain, fever, and jaundice, is the classical clinical manifestation of acute cholangitis though not all patients manifest with the triad. The diagnosis of acute cholangitis is based on a combination of characteristic clinical features, evidence of systemic inflammation (i.e., leukocytosis, CRP), and evidence of cholestasis (e.g., elevated direct bilirubin, GGT, and ALP). Imaging is primarily used to identify the underlying cause of biliary obstruction. Empiric antibiotic therapy and urgent biliary drainage (e.g., ERCP + papillotomy, EUS-guided biliary drainage) within 48 hours of presentation are the mainstays of treatment. Treatment of the underlying cause (e.g., ERCP-guided stone extraction or CBD stenting) may be performed at the same time as urgent biliary drainage in stable patients with mild cholangitis or deferred until clinical improvement in patients with severe cholangitis.

See also “Cholelithiasis”, “Choledocholithiasis”, and “Acute cholecystitis.”

Epidemiological data refers to the US, unless otherwise specified.

Acute cholangitis is diagnosed based on systemic signs of inflammation (fever, leukocytosis, CRP) in combination with signs of cholestasis (jaundice, GGT, ALP) and/or characteristic imaging findings (e.g., dilated CBD, periductal inflammation). Once the diagnosis is confirmed, disease severity should be assessed to determine the best approach to management (see “Severity grading of acute cholangitis”).

Diagnostic criteria [6][7]

Charcot triad is not included in the diagnostic criteria because, although specific, it is not a sensitive criterion and may even be absent in patients with acute cholangitis. [6]

Diagnostic criteria for acute cholangitis [8]

Systemic signs of inflammation
Signs of cholestasis
Imaging findings

Interpretation

  • Suspected diagnosis: ≥ 1 sign of inflammation PLUS either ≥ 1 sign of cholestasis OR ≥ 1 characteristic imaging findings
  • Definite diagnosis: ≥ 1 sign of inflammation PLUS ≥ 1 sign of cholestasis PLUS ≥ 1 characteristic imaging findings

Laboratory studies [1][4][6][7]

Imaging [6][7][9][10]

Acute cholangitis cannot be diagnosed with imaging alone. The goal of imaging is to evaluate for biliary obstruction that may have precipitated cholangitis. [6]

RUQ Ultrasound

CT scan with IV contrast [9][10][11]

MRI abdomen without and with IV contrast with MRCP

  • Indication: an alternative confirmatory imaging modality if ultrasound is inconclusive [9][10][14]
  • Supportive findings: similar to CT findings

Severity grading [6][7]

Once the diagnosis is confirmed, disease severity should be assessed to determine the best approach to treatment.

Severity grading for acute cholangitis [6][7]
Grades of severity Grading criteria [6]

Grade I

(Mild acute cholangitis)

  • Acute cholangitis with no evidence of organ dysfunction
  • Does not meet any criteria of grade II or III acute cholangitis

Grade II

(Moderate acute cholangitis)

  • Acute cholangitis PLUS any two of the following:
    • WBC count > 12,000/mm3 or < 4,000/mm3
    • Temperature ≥ 39°C
    • Age ≥ 75 years
    • Total serum bilirubin ≥ 5 mg/dL
    • Serum albumin less than 70% of lower limit of normal

Grade III

(Severe acute cholangitis)

The differential diagnoses listed here are not exhaustive.

Empiric antibiotic therapy and urgent biliary drainage are the mainstays of treatment of acute cholangitis. The choice and timing of both biliary drainage and any procedure to treat the underlying cause are dictated by the severity of the disease at presentation (see “Severity grading of acute cholangitis”).

Approach [2][7][15][16]

Initiate supportive therapy and broad-spectrum antibiotics as early as possible!

Initial medical management [7]

Definitive management [6][7][16][17]

  • Grade I acute cholangitis
    • Antibiotic therapy alone may be sufficient.
    • Consider urgent biliary drainage within 24–48 hours of presentation in patients with either of the following:
    • Treatment of the underlying cause should be performed concurrently with biliary drainage
  • Grade II acute cholangitis
    • Urgent biliary drainage within 24–48 hours of presentation
    • Treatment of the underlying cause once the patient's clinical condition improves
  • Grade III acute cholangitis
    • Urgent biliary drainage within 24 hours of presentation [7][18]
    • Treatment of the underlying cause once the patient's clinical condition improves

Procedures [16][19]

  • Therapeutic ERCP-guided transpapillary biliary drainage
  • EUS-guided biliary drainage [16][20][21]
    • Indications
      • Second-line procedure if ERCP-guided drainage is unsuccessful
      • Second-line procedure if balloon-enteroscopy-assisted ERCP is not feasible in patients with altered upper gastrointestinal anatomy
    • Procedure: Under EUS guidance, a fistula is created and a stent placed between the stomach/duodenum and the CBD/(dilated) hepatic duct to allow for internal biliary drainage.
  • Double balloon enteroscopy-assisted ERCP [16][22]
    • Indication: Preferred procedure for biliary drainage in patients with altered upper gastrointestinal anatomy, if endoscopy expertise is available
    • Procedure: An enteroscope is used to maneuver through the gastroenteric/enteroenteric anastomosis until the duodenal papilla is identified; after which ERCP-guided papillotomy or stenting may be performed.
  • Percutaneous transhepatic biliary drainage (PTBD) [16]
    • Indication: EUS-guided drainage unsuccessful or not feasible
    • Procedure: Under ultrasound guidance and use of the Seldinger technique, a catheter is passed through the liver and placed into an intrahepatic bile duct to allow for external biliary drainage.
  • Surgical choledochotomy with T-tube biliary drainage [16][23]
    • Indication: Consider if minimally invasive endoscopic and percutaneous biliary drainage procedures are unsuccessful or not feasible
    • Procedure: The CBD is opened laparoscopically or via open surgery (choledochotomy), a T-tube placed within the CBD, and the choledochotomy closed around the T-tube. The long limb of the T-tube is brought out through the abdominal wall to allow for external biliary drainage. [24]

Bile obtained during the biliary drainage procedure should be sent for culture and sensitivity, and antibiotic therapy tailored accordingly.

Treatment of the underlying cause [7]

Disposition [7]

All patients require inpatient management.

We list the most important complications. The selection is not exhaustive.

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