From the Guidelines
Cholangitis does not always present with elevated liver enzymes, as infections can be limited to small liver segments, and patients may have no significant change in baseline liver biochemistry. In cholangitis, which is an infection or inflammation of the bile ducts, liver enzymes such as alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) may be elevated, but this is not a universal finding 1. The pattern of enzyme elevation can vary, with some patients showing a more prominent increase in cholestatic enzymes (ALP and GGT) compared to transaminases (AST and ALT). This elevation occurs because the inflammation and obstruction of bile ducts impairs bile flow, causing bile acids to accumulate and damage liver cells. According to the most recent guidelines, patients with cholangitis may present with a wide spectrum of severity and can be atypical, and standard definitions for acute cholangitis may not be universally applicable 1.
Some key points to consider in the diagnosis and management of cholangitis include:
- Bacterial cholangitis is an important and common complication of primary sclerosing cholangitis (PSC) and usually occurs in patients with a high-grade biliary stricture 1
- An episode of acute bacterial cholangitis should elicit imaging/MRCP studies for assessment of potentially flow-limiting biliary strictures and when necessary biliary intervention/ERCP 1
- Patients with severe acute cholangitis and dominant bile duct strictures require urgent biliary decompression, as the mortality in those untreated is high 1
- The choice of antibiotic agent should be directed by local practice after taking into consideration the history, severity of liver or renal disease, and bacterial sensitivities 1
In terms of treatment, prompt administration of appropriate antibiotics such as piperacillin-tazobactam, ciprofloxacin plus metronidazole, or a third-generation cephalosporin is essential, along with biliary decompression procedures in cases of obstructive cholangitis to relieve the blockage and restore normal bile flow. However, the most recent and highest quality study 1 suggests that the diagnosis and management of cholangitis should be individualized and based on the specific clinical presentation and underlying disease.
From the Research
Cholangitis and Elevated Liver Enzymes
- Cholangitis is a condition characterized by inflammation of the bile ducts, which can lead to elevated liver enzymes 2, 3.
- Studies have shown that patients with cholangitis often have elevated serum levels of alkaline phosphatase, gamma-glutamyl transpeptidase, and bilirubin 2, 4.
- Elevated liver enzymes are a common feature of cholangitis, and can be used as a diagnostic marker for the condition 3, 5.
- Treatment of cholangitis often involves the use of ursodeoxycholic acid, which has been shown to improve liver function and reduce disease activity 2, 5, 6.
Types of Cholangitis
- Primary sclerosing cholangitis (PSC) is a type of cholangitis characterized by inflammation and fibrosis of the bile ducts, leading to elevated liver enzymes 2, 5.
- Autoimmune cholangitis is another type of cholangitis, which is characterized by elevated liver enzymes and the presence of autoantibodies 4.
- Cholangitis can also be complicated by infection, which can lead to further elevation of liver enzymes 3.
Diagnosis and Treatment
- Diagnosis of cholangitis is often based on a combination of clinical presentation, laboratory tests, and imaging studies 2, 3, 6.
- Treatment of cholangitis depends on the underlying cause and severity of the condition, but often involves the use of ursodeoxycholic acid and other medications to reduce inflammation and improve liver function 2, 4, 5, 6.