From the Guidelines
No, fever is not a prerequisite for cholangitis, although it is a common feature of the condition. Cholangitis is an infection of the bile ducts that can present with a range of symptoms. The classic presentation, known as Charcot's triad, includes fever, right upper quadrant pain, and jaundice, but not all patients will exhibit all three symptoms. Some patients, particularly elderly individuals or those who are immunocompromised, may present with atypical symptoms or even without fever, as noted in the EASL clinical practice guidelines on sclerosing cholangitis 1. Other symptoms of cholangitis can include nausea, vomiting, lethargy, confusion, and hypotension in severe cases. The absence of fever should not rule out cholangitis if other clinical features and laboratory findings (such as elevated liver enzymes, bilirubin, or white blood cell count) suggest the diagnosis.
Key considerations in the management of cholangitis include:
- Prompt diagnosis and treatment with appropriate antibiotics, such as piperacillin-tazobactam, ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole, as recommended by the 2017 WSES guidelines for management of intra-abdominal infections 1
- Biliary drainage procedures, which are essential for restoring biliary drainage in case of obstruction, as emphasized in the ACR Appropriateness Criteria for radiologic management of biliary obstruction 1
- Early interventional approach in severe cholangitis, which is absolutely essential for survival, as highlighted in the 2017 WSES guidelines 1
The clinical presentation of cholangitis can vary, and initial risk stratification is important to guide further management, as noted in the 2017 WSES guidelines 1. The type and timing of biliary drainage should be based on the severity of the clinical presentation, and the availability and feasibility of drainage techniques, such as endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), and open surgical drainage. ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis, as recommended by the 2017 WSES guidelines 1.
From the Research
Definition and Diagnosis of Cholangitis
- Cholangitis is an infection of the biliary ductal system that results from the combination of bactibilia and biliary obstruction 2.
- The complete triad of fever and chills, jaundice, and abdominal pain, as originally described by Charcot, is now seen less frequently due to changes in the causes of cholangitis 2.
- Most patients still have leukocytosis and abnormal liver function tests, but many patients with indwelling tubes may develop cholangitis without significant jaundice 2.
Fever as a Prerequisite for Cholangitis
- Fever is a common symptom of cholangitis, but it is not a prerequisite for the diagnosis 3.
- Cholangitis can be diagnosed by the presence of clinical features, laboratory tests, and imaging studies, even in the absence of fever 3.
- The treatment modalities for cholangitis include administration of intravenous fluids, antimicrobial therapy, and prompt drainage of the bile duct, regardless of the presence of fever 3.
Treatment and Management of Cholangitis
- Initial therapy for cholangitis includes bowel rest, intravenous fluids, and antibiotics 2.
- The choice of antibiotics should reflect local resistance patterns and avoid the overuse of broad-spectrum agents 4.
- Computed cholangiography is usually necessary to determine the cause and site of biliary obstruction, and can be delayed until the patient has been afebrile for a minimum of 24 to 48 hours 2.
- Early diagnosis and treatment of acute cholangitis are crucial to prevent unwanted clinical outcomes of the disease 3.