Triggers of Acute Cholangitis with Fever and Right Upper Quadrant Abdominal Pain
Biliary obstruction is the primary trigger for acute cholangitis, with the most common causes being gallstones, biliary strictures, and malignant obstruction. 1, 2
Clinical Presentation
- Acute cholangitis classically presents with Charcot's triad: fever, right upper quadrant abdominal pain, and jaundice 3
- Laboratory findings typically include indicators of inflammation (leukocytosis) and biliary stasis (elevated bilirubin, alkaline phosphatase, GGT) 1
- Imaging findings show biliary dilatation or evidence of an etiology such as stricture, stone, or obstructing mass 4
Common Causes of Biliary Obstruction Leading to Cholangitis
Gallstones (Choledocholithiasis)
- Historically the leading cause of acute cholangitis 5
- Stones in the common bile duct obstruct bile flow, leading to increased biliary pressure and bacterial proliferation 6
- Increased biliary pressure causes biliovenous reflux of bacteria and purulent bile into circulation, leading to systemic inflammation and sepsis 6
Biliary Strictures
- Can be benign or malignant in nature 7
- Benign strictures may result from:
- Previous biliary surgery
- Chronic pancreatitis
- Primary sclerosing cholangitis
- IgG4-related sclerosing cholangitis 3
Malignant Obstruction
- Pancreatic cancer, cholangiocarcinoma, or metastatic disease 7
- Notably, malignant obstruction typically causes cholangitis only after prior instrumentation (such as stent placement) 7
Iatrogenic Causes
- Biliary instrumentation (ERCP, stent placement)
- Indwelling biliary tubes/stents that may become occluded 5
- In tertiary referral centers, nonoperative biliary manipulations have become the most common cause of cholangitis 5
Microbiology of Cholangitis
- Infections are typically polymicrobial 2
- Most common isolates include:
- Enterococcus species
- Escherichia coli
- Enterobacter species
- Klebsiella species 7
- Patients with indwelling tubes or prior antibiotic exposure may have resistant organisms including Pseudomonas species and yeasts 5
- 72% of patients have at least one resistant organism present in blood cultures 7
Pathophysiology
- Biliary obstruction leads to increased biliary pressure 6
- Bacterial colonization of bile occurs (bactibilia) 5
- The combination of obstruction and infection results in cholangitis 5
- Increased pressure causes biliovenous reflux, leading to bacteremia and systemic inflammation 6
Severity Classification
- The Tokyo Guidelines stratify cholangitis into three grades to guide management 4:
- Grade 1 (mild): Responds to medical therapy
- Grade 2 (moderate): Requires early biliary decompression
- Grade 3 (severe): Requires urgent biliary decompression 4
Diagnostic Approach
- Abdominal ultrasound is recommended as the first-line imaging modality 4
- If ultrasound is equivocal, CT with IV contrast is recommended as the next step 4
- For persistent suspicion after inconclusive CT, MRI/MRCP is recommended 4
- Blood and bile cultures should be routinely performed to guide antibiotic therapy, as resistant organisms are common 7
Management Considerations
- Early antibiotic therapy is crucial (within 1 hour for sepsis, within 6 hours for less severe cases) 4
- Timing of biliary decompression depends on severity:
- Severe (grade 3): Urgent decompression
- Moderate (grade 2): Early decompression (within 24 hours)
- Mild (grade 1): Can be initially observed on medical treatment 4
- ERCP with stent placement is the procedure of choice for biliary decompression 4
Common Pitfalls
- Delaying biliary decompression beyond 24 hours in moderate to severe cases increases mortality 1
- Failing to obtain blood or bile cultures may lead to inadequate antibiotic coverage, as resistant organisms are common 7
- Overlooking the possibility of cholangitis in patients with indwelling biliary tubes who may develop infection without significant jaundice 5