Diagnostic Criteria for Cholangitis
Diagnose acute cholangitis when a patient presents with clinical signs of systemic inflammation (fever/chills), evidence of cholestasis (jaundice), and abdominal pain (right upper quadrant), supported by laboratory markers of inflammation and imaging demonstrating biliary obstruction. 1
Clinical Manifestations (Charcot's Triad)
The diagnosis requires assessment of three key clinical components 2:
- Fever and/or chills - indicating systemic inflammatory response 2
- Abdominal pain - specifically right upper quadrant or epigastric location 2
- Jaundice - reflecting biliary obstruction 2
Important caveat: When not all components of Charcot's triad are present, you can still make a definite diagnosis if laboratory and imaging findings support inflammation and biliary obstruction 2. Physical examination may reveal ictericia, hepatomegaly, and splenomegaly in approximately half of symptomatic patients 1.
Laboratory Findings
Essential laboratory markers include 1:
- Elevated alkaline phosphatase - the most common biochemical abnormality 1
- Elevated aminotransferases 1
- Inflammatory markers - leucocytosis and elevated C-reactive protein 1
- Elevated bilirubin - supporting cholestasis 3
Imaging Studies
Abdominal ultrasound is the mandatory first-line imaging modality for suspected cholangitis 1, 4. Ultrasound effectively demonstrates biliary dilatation, though this may not be present in early-stage obstruction 5.
If ultrasound is equivocal or non-diagnostic and clinical suspicion persists, obtain an abdominal CT scan 1. CT without contrast is more sensitive than ultrasound for detecting choledocholithiasis 5.
For definitive determination of the underlying cause and level of obstruction, magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) are the most sensitive techniques 5.
Severity Grading (Tokyo Guidelines)
Once diagnosed, classify severity into three grades 2:
- Severe (Grade III): Acute cholangitis with at least one new-onset organ dysfunction 2
- Moderate (Grade II): No organ dysfunction but fails to respond to initial medical treatment, with persistent or worsening clinical manifestations and/or laboratory abnormalities 2
- Mild (Grade I): Responds to initial medical treatment with improvement in clinical findings 2
Critical Pitfalls to Avoid
- Do not wait for complete Charcot's triad - diagnosis can be made with supportive laboratory and imaging findings even when clinical triad is incomplete 2
- Do not rely solely on ultrasound - biliary dilatation may be absent early in obstruction, and ultrasound has poor performance for detecting choledocholithiasis 5
- Distinguish primary from secondary cholangitis - consider clinical history, cholangiographic distribution patterns, and presence/absence of inflammatory bowel disease 1
- Recognize secondary causes - including AIDS cholangiopathy, cholangiocarcinoma, choledocholithiasis, IgG4-related cholangitis, and surgical biliary trauma 1