Symptoms of Ascending Cholangitis
The classic symptoms of ascending cholangitis include fever, right upper quadrant pain, and jaundice (Charcot's triad), which occurs when bacteria infect an obstructed biliary system. 1
Clinical Presentation
Cardinal Symptoms
- Fever and chills: Present in most cases, indicating systemic infection
- Right upper quadrant abdominal pain: Often moderate to severe
- Jaundice: Yellowing of skin and sclera due to biliary obstruction
- Pruritus: Itching due to bile salt accumulation in the skin
Severe Presentation
In more advanced cases, patients may develop:
- Hypotension
- Altered mental status
- These two symptoms, when combined with Charcot's triad, form Reynolds' pentad, indicating severe, potentially life-threatening cholangitis 2
Laboratory Findings
- Leukocytosis: Elevated white blood cell count
- Elevated liver enzymes: Particularly alkaline phosphatase (ALP) and γ-glutamyl transpeptidase
- Elevated bilirubin: Present in 28-40% of cases 3
- Positive blood cultures: Found in approximately 40% of cases 1
Diagnostic Considerations
The Tokyo Guidelines recommend diagnosis based on:
- Systemic inflammation (fever/chills or laboratory evidence of inflammatory response)
- Cholestasis (jaundice, abnormal liver function tests)
- Imaging evidence of biliary dilatation or etiology (stone, stricture, stent) 1
Common Causes
- Choledocholithiasis (gallstones in the bile duct): Most common cause
- Malignant biliary obstruction: From pancreatic cancer, cholangiocarcinoma
- Benign biliary strictures: Post-surgical or inflammatory
- Biliary stent occlusion: In patients with previously placed biliary stents 4
Risk Factors
- History of gallstones
- Recent biliary instrumentation
- Biliary tract malignancy
- Prior biliary-enteric anastomosis
- Immunocompromised state
Complications
If not promptly treated, ascending cholangitis can lead to:
- Septic shock
- Acute kidney injury
- Multiple organ dysfunction syndrome
- Liver abscess formation
- Death (mortality rate approximately 5% despite improved management) 1
Clinical Pitfalls to Avoid
- Relying solely on Charcot's triad for diagnosis (present in only 50-70% of cases)
- Delaying antibiotic therapy while awaiting confirmatory imaging
- Failing to obtain blood cultures before initiating antibiotics
- Overlooking the need for urgent biliary decompression in severe cases
- Underestimating the severity of illness in elderly or immunocompromised patients
Early recognition of ascending cholangitis symptoms and prompt initiation of appropriate antibiotics and biliary drainage are essential to prevent progression to severe disease and reduce mortality.