What are the symptoms and treatment of acute cholangitis?

Acute Cholangitis: Symptoms and Treatment

Acute cholangitis is characterized by the classic triad of fever, jaundice, and right upper quadrant abdominal pain, and requires prompt diagnosis and treatment with antibiotics and biliary decompression to prevent life-threatening complications. 1

Clinical Presentation

• The classic presentation of acute cholangitis includes Charcot's triad: fever and/or chills, right upper quadrant or epigastric abdominal pain, and jaundice 2
• Not all patients present with the complete triad; diagnosis can still be made with partial presentation plus laboratory evidence of inflammation and biliary obstruction 2
• Laboratory findings typically include elevated inflammatory markers (leukocytosis, elevated C-reactive protein) and indicators of biliary stasis (elevated bilirubin, alkaline phosphatase) 1
• The most important predisposing factor is biliary obstruction, without which cholangitis does not develop 1

Diagnostic Approach

• Diagnosis should include clinical signs (jaundice, fever, chills, right upper quadrant pain), laboratory findings (indicators of inflammation and biliary stasis), and imaging findings (biliary dilatation or evidence of an etiology such as stricture, stone, or obstructing mass) 1
• Ultrasound is recommended as the initial diagnostic imaging modality for suspected acute cholangitis 1
• If initial ultrasound is equivocal/non-diagnostic and clinical suspicion persists, CT scan with IV contrast is suggested as subsequent imaging 1
• If both US and CT are inconclusive but acute cholangitis is still suspected, MRI/MRCP is a reasonable option 1

Severity Assessment

• Acute cholangitis can be classified into three grades based on severity 2:
  • Mild (grade I): responds to initial medical treatment with improved clinical findings
  • Moderate (grade II): does not respond to initial medical treatment, but without organ dysfunction
  • Severe (grade III): accompanied by at least one new-onset organ dysfunction

Treatment Algorithm

Medical Management

• Timely initiation of antimicrobial therapy is crucial for improving survival 1:
  • For patients with sepsis: antibiotics within 1 hour of diagnosis
  • For less severe cases: antibiotics within 6 hours of diagnosis
• Fluid resuscitation and correction of coagulopathies are essential components of initial management 1
• Pain management typically includes opioids for severe pain, with acetaminophen and NSAIDs as part of a multimodal approach 3

Biliary Decompression

• Timing of biliary decompression depends on the severity of acute cholangitis 1:
  • Severe (grade 3): requires urgent decompression
  • Moderate (grade 2): requires early decompression (within 24 hours of admission)
  • Mild (grade 1): can be initially observed on medical treatment
• Early biliary drainage (within 24 hours of admission) is associated with significantly lower 30-day mortality in grade 2 acute cholangitis 1
• Hospital stays are shorter for patients treated with biliary drainage within 24 hours of hospital admission, regardless of severity 1

Drainage Procedures

• ERCP with stent placement is the procedure of choice for biliary decompression 1
• Endoscopic transpapillary biliary drainage is recommended as the first-line procedure due to lower risk of adverse events and less invasiveness than percutaneous drainage or surgical drainage 1
• Percutaneous transhepatic biliary drainage (PTBD) is indicated when endoscopic approaches fail or are not feasible 1, 4
• Open surgical drainage is now extremely rare due to the widespread use of endoscopic or percutaneous techniques 1

Complications and Pitfalls

• Acute cholangitis can rapidly progress to a severe form with organ dysfunction due to systemic inflammatory response syndrome (SIRS) and/or sepsis 2
• Delayed intervention is associated with elevated morbidity and mortality rates, increased likelihood of ICU admission, and prolonged hospitalization 1
• ERCP-related complications include pancreatitis (most common, 1.6%-15.7%), hemorrhage (1.3%), and post-ERCP cholangitis (less than 1%) 1
• Percutaneous drainage has a complication rate of approximately 7%, though these typically do not contribute to subsequent morbidity and mortality 4

Special Considerations

• In pregnant patients with suspected acute cholangitis, either ultrasound or MRI can be considered as the initial diagnostic imaging modality 1
• For children with suspected acute cholangitis, it is reasonable to follow the same imaging pathway as for adults 1