From the Guidelines
Diagnosing cholangitis requires a combination of clinical presentation, laboratory tests, and imaging studies, with a focus on identifying biliary obstruction and potential causes like stones, as outlined in the Tokyo Guidelines 2013 (TG13) 1. The diagnosis of cholangitis involves recognizing the classic Charcot's triad of fever, right upper quadrant abdominal pain, and jaundice, though this is present in only 50-70% of cases. Initial evaluation should include a thorough history and physical examination, followed by laboratory tests including complete blood count, liver function tests, and blood cultures. Imaging studies are essential, with ultrasound typically performed first to identify biliary dilation and potential obstructing causes like stones.
- Key laboratory tests include:
- Complete blood count to look for leukocytosis
- Liver function tests to evaluate elevated bilirubin, alkaline phosphatase, and transaminases
- Blood cultures, which are positive in 50-80% of cases
- Imaging studies should include:
- Ultrasound to identify biliary dilation and potential obstructing causes like stones
- Magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) for more definitive imaging, as both are effective for common bile duct (CBD) stones 1
- Computed tomography (CT) to help identify complications like abscesses The diagnosis is confirmed by the combination of clinical presentation, laboratory abnormalities showing cholestasis and inflammation, and imaging evidence of biliary obstruction. Prompt diagnosis is critical as cholangitis can rapidly progress to sepsis, with mortality rates of 5-10% even with appropriate treatment. Patients with suspected cholangitis should be hospitalized immediately for intravenous antibiotics and consideration of urgent biliary drainage, with early laparoscopic exploration also an option for stone-related nonsevere acute cholangitis besides endoscopic retrograde cholangial or percutaneous transhepatic cholangial drainage 1.
From the Research
Diagnosis of Cholangitis
To diagnose cholangitis, the following steps can be taken:
- Clinical presentation: The diagnosis of acute cholangitis is based on clinical presentation and laboratory data indicating systemic infection, as well as diagnostic imaging modalities revealing signs of biliary obstruction and possibly an underlying etiology 2.
- Laboratory tests: Laboratory tests, such as blood cultures, can help identify the presence of bacteria, with Escherichia coli and Klebsiella spp. being the main pathogens involved 3.
- Imaging studies: Imaging studies, such as abdominal ultrasound, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and CT scan, can help explore the biliary tract and identify signs of biliary obstruction 2, 4, 3.
- Diagnostic criteria: The Tokyo Guidelines introduce a new score that includes biological and radiological data to aid in the diagnosis of acute cholangitis 3.
- Charcot's triad: Clinical diagnosis can also rely on Charcot's triad, which includes pain, fever, and jaundice, although its sensitivity is insufficient 3.
Diagnostic Imaging Modalities
The following diagnostic imaging modalities can be used to diagnose cholangitis:
- Endoscopic retrograde cholangiopancreatography (ERCP): ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis 2, 4.
- Percutaneous transhepatic cholangiography (PTC): PTC can be used as an alternative to ERCP for second-line therapy if ERCP fails or is not possible 2.
- Endoscopic ultrasound-guided biliary drainage: This modality has recently emerged as a possible alternative to PTC for second-line therapy if ERCP fails or is not possible 2.
- Magnetic resonance cholangiopancreatography: This modality has excellent diagnostic capacities and can help identify signs of biliary obstruction 4, 3.
- CT scan: CT scan has intermediate diagnostic capacities and can be used to explore the biliary tract 3.