Acute Gallstone Cholangitis

Aka: Acute Gallstone Cholangitis, Ascending Cholangitis, Cholangitis, Suppurative Cholangitis, Charcot's Triad, Reynold's Pentad, Acute Cholangitis

II. Epidemiology

  1. Incidence rare under age 40 years
    1. However can occur in children with risk factors

III. Risk Factors

  1. Choledocolithiasis
  2. Biliary atresia or Biliary tract stricture
  3. Surgical anastomotic stricture
  4. Extrinsic compression from malignancy
  5. Liver transplant history
  6. Roux-en-Y Bypass Surgery

IV. Pathophysiology

  1. Reflux of Bacteria into the lymphatics, hepatitic veins
    1. Results in systemic spread
  2. Complete biliary obstruction in presence of Bacteria (Gram Negative Bacteria, Anaerobic Bacteria)
    1. E. coli (25-50%)
    2. Klebsiella (15-20%)
    3. Enterobacter (5-10%)
    4. Enterococcus (10-20%)
    5. Bacteroides
    6. Clostridium
    7. Pseudomonas

V. Symptoms

  1. See Acute Cholecystitis
  2. See Biliary Colic
  3. Nausea or Vomiting

VI. Signs

  1. Charcot's Triad (seen in only 25% of patients)
    1. Fever
    2. Jaundice
    3. Right Upper Quadrant Abdominal Pain
  2. Reynold's Pentad (seen in only 14% of patients)
    1. Charcot's Triad and
    2. Hypotension (Shock) and
    3. Altered Mental Status
  3. Other findings
    1. Toxic appearance
    2. Hepatomegaly (with tender liver edge)
    3. Splenomegaly

VII. Labs

  1. Complete Blood Count
    1. Leukocytosis
  2. Liver Function Tests abnormal
    1. Bilirubin elevated in urine and plasma (40% of cases)
    2. Serum alkaline phsophatase elevated
  3. Blood Cultures (positive in 50% of cases)

VIII. Differential Diagnosis

  1. Acute Cholecystitis
  2. Post-op status (esp. Laparoscopic Cholecystectomy) Bile Duct Injury with Biliary Leak
  3. Acute Pancreatitis
  4. Liver Abscess

IX. Prognosis

  1. Mortality 100% if missed or incorrectly treated

X. Management

  1. See Acute Cholecystitis
  2. See Cholecystectomy
  3. Broad spectrum parenteral antibiotics
    1. Initial antibiotic regimen
      1. Piperacillin-Tazobactam 4.5 g IV q8 hours OR
      2. Ertapenem 1 g IV every 24 hours OR
    2. Initial antibiotic regimen for life threatening infection
      1. Imipenem 0.5 g IV every 6 hours OR
      2. Meropenem 1 g IV every 8 hours OR
      3. Doripenem 500 mg IV every 8 hours
    3. Initial antibiotic regimen for mild to moderate community acquired infection
      1. Cefazolin
      2. Cefuroxime
      3. Ceftriaxone
    4. Alternative antibiotic regimens
      1. Metronidazole 1 g IV load, then 500 mg IV every 6 hours AND
      2. Ceftriaxone 2 g IV OR (Moxifloxacin 400 IV q24h or Ciprofloxacin 400 mg IV q12 h)
        1. Risk of Fluoroquinolone resistance
    5. Additional antibiotics
      1. Vancomycin
        1. Added to regimen if Healthcare Associated Infection
    6. References
      1. (2019) Acute Cholangitis, Sanford Guide, accessed 3/29/2019
      2. (2019) Acute Cholangitis, UpToDate, accessed 3/29/2019
  4. Sepsis management
    1. See Septic Shock
    2. Volume Resuscitation
    3. Vasopressor support as needed
  5. Rapid decompression of biliary tree
    1. Endoscopy with ERCP and sphincterotomy
      1. May be preferred as initial intervention
    2. Open common bile duct exploration
      1. High mortality and morbidity

XI. References

  1. Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]
  2. Poon (2001) Arch Surg 136:11-6 [PubMed]
  3. Portincasa (2006) Lancet 368(9531):230-9 [PubMed]

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Related Studies

Ontology: Cholangitis (C0008311)

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
Derived from the NIH UMLS (Unified Medical Language System)

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
Derived from the NIH UMLS (Unified Medical Language System)

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, ｼﾞｮｳｺｳｾｲﾀﾝｶﾝｴﾝ
Czech Ascendentní cholangitida
Hungarian ascendáló cholangitis
Derived from the NIH UMLS (Unified Medical Language System)

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