Can cholangitis occur after gallbladder removal?

Cholangitis After Gallbladder Removal

Yes, cholangitis can definitely occur after gallbladder removal, as the common bile duct and biliary tree remain intact and can still become infected and inflamed even without a gallbladder present. 1

Pathophysiology of Post-Cholecystectomy Cholangitis

• Cholangitis after cholecystectomy typically occurs due to obstruction of the common bile duct, most commonly from residual or recurrent stones, biliary strictures, or stent occlusion 1
• Without a gallbladder, bile flows directly from the liver into the common bile duct and then into the duodenum, but this pathway can still become obstructed 1
• Recurrent cholangitis is a main consequence of bile duct stricture, which can develop after bile duct injury during cholecystectomy 1

Clinical Presentation

• Patients with post-cholecystectomy cholangitis typically present with:
  • Fever with chills
  • Jaundice
  • Right upper quadrant abdominal pain
  • Nausea and vomiting 1
• These symptoms are often referred to as Charcot's triad and are consistent with cholangitis regardless of whether the gallbladder is present or not 1

Common Causes of Post-Cholecystectomy Cholangitis

1. Residual or Recurrent Common Bile Duct Stones

   • Stones may be left behind during cholecystectomy or form later in the bile duct 1
   • Risk of recurrent stones is higher in patients who had endoscopic sphincterotomy without cholecystectomy 2, 3

2. Biliary Strictures

   • Can develop as a complication of cholecystectomy due to bile duct injury 1
   • May lead to bile stasis and subsequent infection 1

3. Biliary Stent Occlusion

   • In patients with indwelling biliary stents, clogging can occur, leading to cholangitis 4
   • Stent occlusion typically occurs within 3-6 months of placement 4

4. Bile Duct Injury During Surgery

   • Iatrogenic bile duct injuries during cholecystectomy can lead to strictures and recurrent cholangitis 1
   • If undiagnosed or improperly repaired, these injuries can progress to secondary biliary cirrhosis 1

Diagnosis

• Laboratory Tests:

  • Elevated liver function tests, particularly direct bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transpeptidase (GGT) 1
  • Elevated white blood cell count indicating infection 1

• Imaging:

  • Abdominal triphasic CT is recommended as first-line imaging to detect fluid collections and ductal dilation 1
  • Contrast-enhanced MRCP provides detailed visualization of the biliary tree and is essential for planning treatment 1
  • ERCP is both diagnostic and therapeutic 5

Management

• Antibiotic Therapy:

  • Prompt initiation of broad-spectrum antibiotics covering gram-negative aerobes and anaerobes 1
  • Treatment should be adapted according to bile culture findings 1
  • Duration typically 5-7 days for biliary infections 1

• Biliary Drainage:

  • ERCP with sphincterotomy and stone extraction is the first-line treatment for cholangitis due to bile duct stones 1, 5
  • For strictures, ERCP with stent placement may be required 5
  • In cases where ERCP fails, percutaneous transhepatic biliary drainage (PTBD) may be necessary 5

• Definitive Treatment:

  • For recurrent stones, complete endoscopic clearance of the bile duct 1
  • For biliary strictures, endoscopic dilation and stenting or surgical repair may be needed 1
  • Stents placed for benign conditions should be removed or exchanged within 3-6 months to prevent occlusion and cholangitis 4

Prevention

• Complete clearance of bile duct stones during initial treatment 1
• Proper surgical technique during cholecystectomy to avoid bile duct injury 1
• Regular exchange of biliary stents if long-term stenting is required 4

Prognosis

• With prompt diagnosis and appropriate treatment, most patients recover well 6
• Delayed diagnosis or inadequate treatment can lead to sepsis, multiorgan failure, and death 1
• Undiagnosed or improperly repaired bile duct injuries can progress to secondary biliary cirrhosis with portal hypertension and liver failure 1

Special Considerations

• Patients with a history of sphincterotomy and no cholecystectomy have a significantly higher risk of recurrent biliary symptoms (25% vs 5.9%) compared to those who underwent cholecystectomy 2
• Small-size papillotomy is also a risk factor for recurrent biliary symptoms 2