Acute Gallstone Cholangitis

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

1. See Also
   1. Gallstone (Cholelithiasis)
   2. Biliary Colic
   3. Acute Cholecystitis
   4. Choledocholithiasis
   5. Acalculous Cholecystitis
2. Epidemiology
   1. Incidence rare under age 40 years
      1. However can occur in children with risk factors
3. 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
4. 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
5. Symptoms
   1. See Acute Cholecystitis
   2. See Biliary Colic
   3. Nausea or Vomiting
6. 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
7. 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)
8. Differential Diagnosis
   1. Acute Cholecystitis
   2. Post-op status (esp. Laparoscopic Cholecystectomy) Bile Duct Injury with Biliary Leak
   3. Acute Pancreatitis
   4. Liver Abscess
9. Prognosis
   1. Mortality 100% if missed or incorrectly treated
10. 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
11. 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]