Acute Gallstone Cholangitis

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

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II. Definitions

  1. Ascending Cholangitis
    1. Acute, life threatening infection of the biliary tree by Bacteria ascending from the Small Intestine (duodenum)
    2. Associated with bile duct obstruction (e.g. Common Bile Duct Stone) resulting in hepatic intraductal pressure increase

III. Epidemiology

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

IV. 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

V. Pathophysiology

  1. Complete biliary duct obstruction (e.g. Choledocolithiasis) results in increased hepatic intraductal pressures
  2. Intestinal Bacteria (Gram Negative Bacteria, Anaerobic Bacteria) pass through sphincter of odi from duodenum
    1. E. coli (25-50%)
    2. Klebsiella (15-20%)
    3. Enterobacter (5-10%)
    4. Enterococcus (10-20%)
    5. Bacteroides
    6. Clostridium
    7. Pseudomonas
  3. Reflux of Bacteria into the Lymphatics, hepatitic veins
    1. Results in systemic spread and rapid progression to Sepsis

VI. Symptoms

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

VII. Signs

  1. Presentations may be cryptic
    1. Altered Mental Status
    2. Sepsis with unknown source
  2. Charcot's Triad (Test Sensitivity 25%, Test Specificity 85%)
    1. Fever
    2. Jaundice
    3. Right Upper Quadrant Abdominal Pain
  3. Reynold's Pentad (7 to14% of patients)
    1. Charcot's Triad and
    2. Hypotension (Shock) and
    3. Altered Mental Status
  4. Other findings
    1. Fever (>40% of patients)
    2. Abdominal Pain (>60% of patients)
    3. Jaundice (60 to 70% of patients)
    4. Toxic appearance
    5. Hepatomegaly (with tender liver edge)
    6. Splenomegaly

VIII. Labs

  1. Complete Blood Count
    1. Leukocytosis (>80% of patients)
      1. Leukopenia (<4000/mm3) may be present instead
    2. Neutrophil to Lymphocyte ratio (NLR) >5.3
  2. Liver Function Tests abnormal
    1. Total Bilirubin elevated in urine and plasma (40% of patients)
      1. Greater Specificity for Cholangitis when Total Bilirubin >4 mg/dl
    2. Serum alkaline phsophatase elevated (>90% of patients)
    3. Gamma glutamyl transferase elevated (>90% of patients)
    4. Transaminases (AST, ALT) may also be increased
  3. Blood Cultures (positive in 50 to 70% of patients)
    1. Gram Negative bacteremia

IX. Imaging

  1. RUQ Ultrasound
    1. Dilated common bile duct (>7 mm, or post-Cholecystectomy >10 mm)
    2. Dilated intrahepatic ducts
    3. Test Sensitivity 25-60% for Common Bile Duct Stones
    4. Do not rely on RUQ Ultrasound to exclude Ascending Cholangitis when suspicion is high
      1. Consider serial Ultrasounds and advanced imaging
  2. CT Abdomen and Pelvis with IV Contrast
    1. Dilated and obstructed common bile ducts and intrahepatic ducts (including external compression forces)
    2. Preferred study in evaluating cause and complications from Cholangitis
  3. MRI Abdomen with MRCP
    1. Indicated when CT and Ultrasound are non-diagnostic

X. Differential Diagnosis

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

XI. Grading (Tokyo Guidelines 13)

  1. Severe (1 or more criteria)
    1. Hypotension requiring Vasopressors
    2. Altered Mental Status
    3. PaO2/FIO2 <300
    4. Oliguria
    5. Serum Creatinine >2 mg/dl
    6. INR >1.5
    7. Platelet Count <100,000/mm3
  2. Moderate (2 or more criteria)
    1. White Blood Cell Count >12,000 or <4000/mm3
    2. Fever >=39 C (102.2 F)
    3. Age >= 75 years old
    4. Total Bilirubin >= 5 mg/dl
    5. Albumin <70% of lower limit of normal
  3. Mild
    1. Criteria not sufficient for moderate or severe Cholangitis

XII. Management

  1. See Acute Cholecystitis
  2. See Cholecystectomy
  3. Broad spectrum parenteral antibiotics (Gram Negatives, enteric Streptococcus, Anaerobes)
    1. Initial antibiotic regimen for life threatening infection
      1. Piperacillin-Tazobactam 4.5 g IV q8 hours OR
      2. Ertapenem 1 g IV every 24 hours OR
      3. Other carbapenems
        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
      4. Alternative antibiotic regimen (2 drug regimen)
        1. Metronidazole 1 g IV load, then 500 mg IV every 6 hours AND
        2. Cefepime or Ceftazidime
    2. Initial antibiotic regimen for mild to moderate community acquired infection
      1. Metronidazole 500 mg IV every 6 hours AND
      2. One of the following
        1. Cephalosporin (Cefazolin, Cefuroxime, Ceftriaxone, Cefotaxime) OR
        2. Fluoroquinolone (Moxifloxacin 400 IV q24h or Ciprofloxacin 400 mg IV q12 h)
          1. Risk of Fluoroquinolone resistance
    3. Additional antibiotics if indicated
      1. Vancomycin
        1. May be added to regimen if Healthcare Associated Infection
    4. References
      1. (2019) Acute Cholangitis, Sanford Guide, accessed 3/29/2019
      2. (2019) Acute Cholangitis, UpToDate, accessed 3/29/2019
  4. Sepsis and symptomatic management
    1. See Septic Shock
    2. Volume Resuscitation with IV fluids
    3. Vasopressor support as needed
    4. Opioid Analgesics
    5. Endotracheal Intubation is often required in severe cases
  5. Rapid decompression of biliary tree
    1. Endoscopy with ERCP and sphincterotomy
      1. Preferred as initial intervention (90% success rate)
      2. Emergent ERCP decompression in severe cases
      3. Mild to moderate Cholangitis responds well to antibiotics in 70-80% of patients
        1. ERCP decompression may be delayed 24-48 hours in these cases
        2. Urgent ERCP decompression is indicated if poor response to antibiotics in first 24 hours
      4. Delayed ERCP >48 hours when medical management has failed is associated with worse outcomes
        1. Prolonged hospitalization, ICU stay, Ventilator support, Vasopressor support and organ failure
        2. Increased mortality as high as 80%
    2. Percutaneous drainage of biliary tree
      1. Consider when ERCP not possible (e.g. Roux-en-Y Bypass, whipple resection, duodenal stenosis)
    3. Open common bile duct exploration
      1. High mortality and morbidity
      2. Consider in cases refractory to other measures

XIII. Prognosis

  1. Mortality approaches 100% if untreated
    1. High mortality (up to 30%) even with optimal care

XIV. References

  1. Long and Swaminathan in Swadron (2022) EM:Rap 22(11): 16-21
  2. Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]
  3. Poon (2001) Arch Surg 136:11-6 [PubMed]
  4. 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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