What is acute cholangitis?

Acute Cholangitis: Definition, Diagnosis, and Management

Acute cholangitis is an infectious disease characterized by acute inflammation and infection in the bile ducts resulting from a combination of biliary obstruction and bacterial growth in bile, which can be life-threatening if not promptly treated. 1

Definition and Pathophysiology

• Acute cholangitis results from two main pathophysiologic components: biliary infection and obstruction 1
• Bacteria reach the biliary system either by ascending from the intestine or through the portal venous system 1
• The most common cause of cholangitis is choledocholithiasis (bile duct stones) 1
• Experimental and clinical models demonstrate that cholangitis does not develop without obstruction 1

Clinical Presentation

• Classic presentation includes fever, jaundice, and abdominal pain (Charcot's triad), though many patients do not present with all three symptoms 2
• The clinical spectrum ranges from self-limiting to life-threatening disease with septic shock 1
• An estimated 70% of patients respond to medical treatment comprising supportive care and antimicrobial therapy 1

Diagnostic Approach

Clinical and Laboratory Assessment

• Laboratory tests typically show elevated inflammatory markers, liver function abnormalities, and signs of systemic infection 3
• Blood cultures should be considered, though their routine use remains controversial as they may not affect clinical management 1

Imaging Studies

• Trans-abdominal ultrasound is recommended as the first imaging test due to its wide availability 1

  • High diagnostic accuracy for biliary dilatation, though sensitivity for CBD stone detection is only 25-63% 1
  • Normal bile duct diameter should be less than 8 mm 1

• More advanced imaging options include:

  • MRCP (magnetic resonance cholangiopancreatography): accuracy >90% for detecting CBD stones 1
  • EUS (endoscopic ultrasound): superior for detecting malignant causes and highly sensitive for stone detection 1
  • CT scan: valuable in unstable patients with suspected malignancy or hepatic abscesses 1

Severity Assessment

• The Tokyo Guidelines (TG13) define three grades of severity 1:
  • Grade I (mild): no organ dysfunction
  • Grade II (moderate): risk of increased severity without early biliary drainage
  • Grade III (severe): presence of organ dysfunction

Management

Medical Management

• Antimicrobial therapy should be initiated empirically as early as possible in any patient with suspected cholangitis 1
• Timing of antibiotic administration is critical:
  • For patients with sepsis: within 1 hour of diagnosis 1
  • For less severe cases: within 6 hours of diagnosis 1
• Most pathogens are derived from gastrointestinal microbiota, including Gram-negative enteric bacteria and enterococci 1
• Duration of antibiotic therapy:
  • With successful biliary drainage: can be as short as 3 days after resolution of fever 4
  • With ongoing obstruction: continue until resolution of the anatomical alteration 1

Biliary Decompression

• Timing of biliary decompression depends on severity 1:

  • Grade III (severe): urgent decompression required
  • Grade II (moderate): early decompression (within 24 hours) significantly reduces 30-day mortality
  • Grade I (mild): can be initially observed on medical treatment

• ERCP (endoscopic retrograde cholangiopancreatography) with stent placement is the first-line procedure for biliary decompression 1

  • Demonstrated to be safer and more effective than percutaneous or surgical approaches 1
  • Options include biliary stent or nasobiliary drain placement above the obstruction site ± sphincterotomy 1

• Alternative drainage methods when ERCP fails or is not feasible:

  • Percutaneous transhepatic biliary drainage (PTBD) 1
  • EUS-guided biliary drainage is emerging as an alternative to PTC 5
  • Open surgical drainage is now extremely rare due to widespread use of endoscopic and percutaneous techniques 1

Complications and Outcomes

• Without proper treatment, mortality from severe cholangitis historically approached 100% 2
• With modern management including early antibiotics, fluid resuscitation, and biliary drainage, outcomes have significantly improved 2
• Potential complications of ERCP include pancreatitis (1.6-15.7%), hemorrhage (1.3%), and post-ERCP cholangitis (<1%) 1
• Early biliary drainage (within 24 hours) is associated with shorter hospital stays regardless of disease severity 1

Special Considerations

• In patients with severe biliary sepsis, focus should be on biliary decompression rather than definitive treatment of the obstruction 1
• Bile samples should be obtained for microbial testing at the beginning of any drainage procedure 1
• Antibiotics that are secreted into bile may theoretically have better efficacy 1
• Obesity has been identified as a risk factor for the development of acute cholangitis 1