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. Complete biliary obstruction in presence of Bacteria
      1. Gram Negative Bacteria
      2. Enterococci
      3. Anaerobic bascteria
   2. Reflux of Bacteria into the lymphatics, hepatitic veins
      1. Results in systemic spread
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. Prognosis
   1. Mortality 100% if missed or incorrectly treated
9. Management
   1. Sepsis management
      1. See Septic Shock
      2. Volume Resuscitation
      3. Vasopressor support as needed
      4. Broad spectrum parenteral antibiotics
         1. See Acute Cholecystitis for typical antibiotic coverage
         2. Imipenem 0.5 g IV every 6 hours OR
         3. Meropenem 1 g IV every 8 hours OR
         4. Doripenem 500 mg IV every 8 hours
   2. 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
10. 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]