II. Definitions
- Ascending Cholangitis
- Acute, life threatening infection of the biliary tree by Bacteria ascending from the Small Intestine (duodenum)
- Associated with bile duct obstruction (e.g. Common Bile Duct Stone) resulting in hepatic intraductal pressure increase
III. Epidemiology
-
Incidence rare under age 40 years
- However can occur in children with risk factors
IV. Risk Factors
- Choledocolithiasis
- Biliary atresia or Biliary tract stricture
- Surgical anastomotic stricture
- Extrinsic compression from malignancy
- Liver Transplant history
- Roux-en-Y Bypass Surgery
V. Pathophysiology
- Complete biliary duct obstruction (Choledocolithiasis)
- Results in increased hepatic intraductal pressures
- Intestinal Bacteria (Gram Negative Bacteria, Anaerobic Bacteria) pass through sphincter of odi from duodenum
- E. coli (25-50%)
- Klebsiella (15-20%)
- Enterobacter (5-10%)
- Enterococcus (10-20%)
- Bacteroides
- Clostridium
- Pseudomonas
- Reflux of Bacteria into the Lymphatics, hepatitic veins
- Results in systemic spread and rapid progression to Sepsis
VI. Symptoms
VII. Signs
- Presentations may be cryptic
- Altered Mental Status
- Sepsis with unknown source
- Charcot's Triad (Test Sensitivity 25%, Test Specificity 85%)
- Reynold's Pentad (7 to14% of patients)
- Charcot's Triad and
- Hypotension (Shock) and
- Altered Mental Status
- Other findings
- Fever (>40% of patients)
- Abdominal Pain (>60% of patients)
- Jaundice (60 to 70% of patients)
- Toxic appearance
- Hepatomegaly (with tender liver edge)
- Splenomegaly
VIII. Labs
-
Complete Blood Count
-
Leukocytosis (>80% of patients)
- Leukopenia (<4000/mm3) may be present instead
- Neutrophil to Lymphocyte ratio (NLR) >5.3
-
Leukocytosis (>80% of patients)
-
Liver Function Tests abnormal
- Total Bilirubin elevated in urine and plasma (40% of patients)
- Greater Test Specificity for Cholangitis when Total Bilirubin >4 mg/dl
- Serum alkaline phsophatase elevated (>90% of patients)
- Gamma Glutamyl Transferase elevated (>90% of patients)
- Transaminases (AST, ALT) may also be increased
- Total Bilirubin elevated in urine and plasma (40% of patients)
-
Blood Cultures (positive in 50 to 70% of patients)
- Gram Negative bacteremia
IX. Imaging
-
RUQ Ultrasound
- Dilated common bile duct (>7 mm, or post-Cholecystectomy >10 mm)
- Dilated intrahepatic ducts
- Test Sensitivity 25-60% for Common Bile Duct Stones
- Do not rely on RUQ Ultrasound to exclude Ascending Cholangitis when suspicion is high
- Consider serial Ultrasounds and advanced imaging
-
CT Abdomen and Pelvis with IV Contrast
- Dilated and obstructed common bile ducts and intrahepatic ducts (including external compression forces)
- Preferred study in evaluating cause and complications from Cholangitis
- MRI Abdomen with MRCP
- Indicated when CT and Ultrasound are non-diagnostic
X. Differential Diagnosis
- See Sepsis
- Acute Cholecystitis
- Post-op status (esp. Laparoscopic Cholecystectomy) Bile Duct Injury with Biliary Leak
- Acute Pancreatitis
- Liver Abscess
XI. Grading (Tokyo Guidelines 13)
- Severe (1 or more criteria)
- Hypotension requiring Vasopressors
- Altered Mental Status
- PaO2/FIO2 <300
- Oliguria
- Serum Creatinine >2 mg/dl
- INR >1.5
- Platelet Count <100,000/mm3
- Moderate (2 or more criteria)
- White Blood Cell Count >12,000 or <4000/mm3
- Fever >=39 C (102.2 F)
- Age >= 75 years old
- Total Bilirubin >= 5 mg/dl
- Albumin <70% of lower limit of normal
- Mild
- Criteria not sufficient for moderate or severe Cholangitis
XII. Management
- See Acute Cholecystitis
- See Cholecystectomy
- Broad spectrum ParenteralAntibiotics (Gram Negatives, enteric Streptococcus, Anaerobes)
- Initial Antibiotic regimen for life threatening infection
- Piperacillin-Tazobactam 4.5 g IV q8 hours OR
- Ertapenem 1 g IV every 24 hours OR
- Other Carbapenems
- Alternative Antibiotic regimen (2 drug regimen)
- Metronidazole 1 g IV load, then 500 mg IV every 6 hours AND
- Cefepime or Ceftazidime
- Initial Antibiotic regimen for mild to moderate community acquired infection
- Metronidazole 500 mg IV every 6 hours AND
- One of the following
- Cephalosporin (Cefazolin, Cefuroxime, Ceftriaxone, Cefotaxime) OR
- Fluoroquinolone (Moxifloxacin 400 IV q24h or Ciprofloxacin 400 mg IV q12 h)
- Risk of Fluoroquinolone resistance
- Additional Antibiotics if indicated
- Vancomycin
- May be added to regimen if Healthcare Associated Infection
- Vancomycin
- References
- (2019) Acute Cholangitis, Sanford Guide, accessed 3/29/2019
- (2019) Acute Cholangitis, UpToDate, accessed 3/29/2019
- Initial Antibiotic regimen for life threatening infection
-
Sepsis and symptomatic management
- See Septic Shock
- Volume Resuscitation with IV fluids
- Vasopressor support as needed
- Opioid Analgesics
- Endotracheal Intubation is often required in severe cases
- Rapid decompression of biliary tree
- Endoscopy with ERCP and sphincterotomy
- Preferred as initial intervention (90% success rate)
- Emergent ERCP decompression in severe cases
- Mild to moderate Cholangitis responds well to Antibiotics in 70-80% of patients
- ERCP decompression may be delayed 24-48 hours in these cases
- Urgent ERCP decompression is indicated if poor response to Antibiotics in first 24 hours
- Delayed ERCP >48 hours when medical management has failed is associated with worse outcomes
- Prolonged hospitalization, ICU stay, Ventilator support, Vasopressor support and organ failure
- Increased mortality as high as 80%
- Percutaneous drainage of biliary tree
- Consider when ERCP not possible (e.g. Roux-en-Y Bypass, whipple resection, duodenal stenosis)
- Open common bile duct exploration
- High mortality and morbidity
- Consider in cases refractory to other measures
- Endoscopy with ERCP and sphincterotomy
XIII. Prognosis
- Mortality approaches 100% if untreated
- High mortality (up to 30%) even with optimal care
XIV. References
- Long and Swaminathan in Swadron (2022) EM:Rap 22(11): 16-21
- Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]
- Poon (2001) Arch Surg 136:11-6 [PubMed]
- Portincasa (2006) Lancet 368(9531):230-9 [PubMed]
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Related Studies
Definition (MSHCZE) | Zánět žlučových cest, zejm. intrahepatálních. Velmi často vzniká po neléčeném uzávěru (obstrukci) žlučových cest kaménkem (srov. choledocholitiáza, cholestáza). V akutním stadiu se projeví bolestmi v pravém podžebří, horečkami, třesavkou, žloutenkou (Charcotova triáda). Méně nápadný je obraz chronického zánětu. Onemocnění je nutné intenzivně léčit (antibiotiky, chirurgickým zákrokem) jinak hrozí i přechod k závažnějšímu jaternímu poškození až cirhóze (sekundární biliární cirhóza). Některé typy ch. vznikají na autoimunitním podkladě např. primární biliární cirhóza. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ ) |
Definition (NCI) | An acute or chronic inflammatory process affecting the biliary tract. |
Definition (NCI_CTCAE) | A disorder characterized by an infectious process involving the biliary tract. |
Definition (MSH) | Inflammation of the biliary ductal system (BILE DUCTS); intrahepatic, extrahepatic, or both. |
Concepts | Disease or Syndrome (T047) |
MSH | D002761 |
ICD9 | 576.1 |
ICD10 | K83.0 |
SnomedCT | 155831003, 197445007, 82403002 |
English | Cholangitides, CHOLANGITIS, Cholangitis NOS, Inflammation bile duct, Cholangitis [Disease/Finding], Cholangitis, bile duct inflammation, cholangitis, cholangeitis, cholangitis (diagnosis), Cholangitis NOS (disorder), Biliary tract infection, Cholangitis (disorder), bile duct; inflammation, inflammation; bile duct, Cholangitis, NOS |
Portuguese | COLANGITE, Colangite NE, Inflamação de canal biliar, Colangite |
Dutch | cholangitis NAO, galwegontsteking, galweg; ontsteking, ontsteking; galweg, cholangitis, Cholangitis |
French | Inflammation des canaux biliaires, Angiocholite SAI, CHOLANGITE, Angiocholite, Cholangite |
German | Entzuendung des Gallengangs, Cholangitis NNB, Cholangiitis, Cholangitis, Gallengangsentzündung |
Italian | Colangite NAS, Infiammazione di dotto biliare, Colangite |
Spanish | Colangitis NEOM, Inflamación de conductos biliares, colangitis, SAI (trastorno), colangitis, SAI, colangitis (trastorno), colangitis, Colangitis |
Japanese | 胆管炎, 胆管の炎症, 胆管炎NOS, タンカンエンNOS, タンカンエン, タンカンノエンショウ |
Swedish | Gallvägsinflammation |
Czech | žlučové cesty - zánět, cholangitida, cholangoitida, zánět žlučových cest, Cholangitida NOS, Zánět žlučových cest, Cholangitida |
Finnish | Sappitietulehdus |
Russian | KHOLANGIT, ХОЛАНГИТ |
Korean | 담관염 |
Croatian | KOLANGITIS |
Polish | Zapalenie dróg żółciowych, Zapalenie przewodów żółciowych |
Hungarian | Cholangitis, epevezeték-gyulladás, Cholangitis k.m.n. |
Norwegian | Gallegangsbetennelse, Kolangitt |
Ontology: Suppurative cholangitis (C0267924)
Concepts | Disease or Syndrome (T047) |
ICD10 | K83.0 |
SnomedCT | 197437002, 69850007 |
English | Cholangitis suppurative, suppurative cholangitis (diagnosis), suppurative cholangitis, Septic cholangitis, Suppurative cholangitis, Suppurative cholangitis (disorder), Suppurative Cholangitis |
Italian | Colangite suppurativa, Colangite settica |
Dutch | septische cholangitis, cholangitis etterend |
French | Cholangite septique, Cholangite suppurée |
German | septische Cholangitis, Cholangitis eitrig |
Portuguese | Colangite séptica, Colangite supurativa |
Spanish | Colangitis séptica, colangitis supurativa (trastorno), colangitis supurativa, Colangitis supurativa |
Japanese | 敗血症性胆管炎, 化膿性胆管炎, ハイケツショウセイタンカンエン, カノウセイタンカンエン |
Czech | Septická cholangitida, Hnisavá cholangitida |
Hungarian | Septicus cholangitis, cholangitis suppurativa |
Ontology: Ascending cholangitis (C0311273)
Definition (NCI) | Acute infection of the bile ducts caused by bacteria ascending from the small intestine. |
Concepts | Disease or Syndrome (T047) |
ICD10 | K83.0 |
SnomedCT | 26918003 |
English | ASCENDING CHOLANGITIS, Cholangitis lenta, Ascending cholangitis, ascending cholangitis, ascending cholangitis (diagnosis), Ascending cholangitis (disorder), Ascending Cholangitis |
Dutch | opstijgende cholangitis |
French | Cholangite ascendante |
German | aufsteigende Cholangitis |
Italian | Colangite ascendente |
Portuguese | Colangite ascendente |
Spanish | Colangitis ascendente, colangitis ascendente (trastorno), colangitis ascendente |
Japanese | 上行性胆管炎, ジョウコウセイタンカンエン |
Czech | Ascendentní cholangitida |
Hungarian | ascendáló cholangitis |