How is ascending cholangitis diagnosed and treated?

Diagnosis and Treatment of Ascending Cholangitis

Ascending cholangitis is diagnosed through a triad of clinical features (fever/chills, right upper quadrant pain, jaundice), laboratory tests showing cholestasis, and imaging evidence of biliary obstruction, with prompt antibiotic therapy and urgent biliary decompression required for severe cases. 1, 2

Diagnostic Approach

Clinical Features

• Charcot's Triad: The classic presentation includes:
  • Fever and/or chills
  • Right upper quadrant or epigastric abdominal pain
  • Jaundice 2

When not all components of Charcot's triad are present, diagnosis can still be made with supporting laboratory and imaging evidence of inflammation and biliary obstruction.

Laboratory Findings

• Elevated white blood cell count
• Cholestatic pattern of liver enzymes:
  • Elevated alkaline phosphatase (most common abnormality)
  • Elevated gamma-glutamyl transferase
  • Elevated bilirubin
  • Moderately elevated transaminases (ALT, AST) 3

Imaging Studies

• Ultrasound: First-line imaging modality

  • Highly sensitive for biliary dilatation
  • Limited sensitivity for detecting stones (particularly in the common bile duct)
  • Note: Early cholangitis may present without biliary dilatation 4

• CT scan: More sensitive than ultrasound for detecting choledocholithiasis 4

• MRCP (Magnetic Resonance Cholangiopancreatography):

  • Most sensitive non-invasive technique for determining cause and level of biliary obstruction
  • Recommended before invasive procedures 4

• ERCP (Endoscopic Retrograde Cholangiopancreatography):

  • Both diagnostic and therapeutic
  • Should be performed after expert multidisciplinary assessment justifies intervention
  • Mandatory pathological sampling of suspicious strictures 3

Severity Assessment

Acute cholangitis is classified into three grades based on organ dysfunction and response to initial treatment 2:

1. Mild (Grade I):

   • Responds to initial medical treatment
   • Clinical findings improve with antibiotics

2. Moderate (Grade II):

   • No organ dysfunction
   • Does not respond to initial medical treatment
   • Clinical manifestations or laboratory data do not improve

3. Severe (Grade III):

   • Accompanied by at least one new-onset organ dysfunction
   • May require intensive care with organ support

Treatment Algorithm

1. Initial Management

• Fluid resuscitation: Intravenous fluids to correct dehydration and maintain hemodynamic stability
• Empiric antibiotics: Start immediately after blood cultures are drawn
  • Common pathogens: E. coli, Klebsiella, Enterococcus, Clostridium, Streptococcus, Pseudomonas, and Bacteroides species 3
  • First-line for mild cases: Fluoroquinolones (e.g., ciprofloxacin)
  • For severe cases: Intravenous cephalosporins or extended-spectrum penicillins with anaerobic coverage 3

2. Biliary Decompression

• Timing: Early biliary decompression (within 24 hours) reduces length of stay, pyrexia, and hemodynamic abnormalities 5

• Urgent decompression required for severe acute cholangitis (Grade III) as mortality is high without treatment 3

• Preferred methods:

  • ERCP with biliary dilatation: Preferred over stenting for dominant strictures 6
  • Percutaneous drainage: Alternative when ERCP fails or for proximal strictures 3

• Important considerations:

  • Prophylactic antibiotics should be administered before ERCP 3, 6
  • Biliary dilatation is preferred to stent insertion 6
  • Mandatory pathological sampling of suspicious strictures to exclude malignancy 3

3. Special Considerations

• Recurrent cholangitis:

  • Consider prophylactic long-term antibiotics for recurrent episodes 6
  • Evaluate for underlying causes (e.g., PSC, strictures, stones)
  • Consider liver transplantation for refractory cases 6

• Fungal infection:

  • Consider antifungal therapy in patients not responding to antibiotics 3

Pitfalls and Caveats

1. Delayed diagnosis: Early cholangitis may present without all components of Charcot's triad and without biliary dilatation on initial imaging.

2. Delayed decompression: Failure to perform timely biliary decompression in severe cholangitis increases mortality.

3. Missing malignancy: Always consider cholangiocarcinoma in patients with PSC who present with worsening cholestasis, weight loss, elevated CA19-9, or new/progressive dominant strictures 3.

4. Antibiotic resistance: Avoid rotation of antibiotics for recurrent cholangitis as this can lead to multiple antibiotic resistances 3.

5. Post-ERCP complications: ERCP carries risks including pancreatitis, bleeding, and perforation. Weigh benefits against risks, especially in high-risk patients.

By following this systematic approach to diagnosis and management, the morbidity and mortality associated with ascending cholangitis can be significantly reduced.