Acute Cholangitis

Reviewed and revised 11 August 2014

OVERVIEW

Acute or ascending cholangitis is a potentially life-threatening systemic infection resulting from inflammation and infection of the biliary tree due to bacterial growth in the bile, usually in the context of biliary obstruction

  • Definitive diagnosis involves (1) a history of biliary disease, (2) the clinical manifestations, (3) laboratory data that indicate the presence of inflammation and biliary obstruction, and (4) imaging findings that indicate biliary obstruction
  • Severity can be graded as follows:
    • mild (grade I) – responsive to treatment, no organ dysfunction
    • moderate (grade II) – unresponsive to treatment, no organ dysfunction
    • severe (grade III) – presence of organ dysfunction

CAUSE

Causative organisms

  • E. coli (up to 50%)
  • Klebsiella spp
  • Enterococcus spp
  • Streptococcus spp
  • Enterobacter spp
  • Pseudomonas aeruginosa
  • rarely due to tropical parasites (e.g. Clonorchis sinensis and Opisthorchis spp )

Pathogenesis

  • cholangiovenous and cholangiolymphatic reflux due to increased intra-biliary pressures as a result of obstruction
  • translocation of pathogenic micro-organisms from the duodenum up the biliary tree and into the bloodstream
  • infection overcomes normal barriers: mucosal barriers, continuous biliary flushing, IgA, Kupffer cells

Underlying cause

  • choledocholithiasis
  • benign stenoses (eg, in primary sclerosing cholangitis, as seen in Figure 1)
  • malignant stenoses
  • biliary stent obstruction
  • strictured bilioenteric anastomoses
  • parasitic colonization of the bile duct
  • procedures (e.g. surgery, ERCP, PTC, biliary sphincterotomy, stent placement, surgical sphincteroplasty, bilioenteric anastomosis)

Predisposing factors

  • gallstones
  • previous cholecystectomy
  • ERCP or cholangiogram
  • previous cholangitis
  • immunocompromise
  • malignancy

CLINICAL FEATURES

History

  • fever (>80%)
  • abdominal pain (especially RUQ) (>80%)
  • nausea and vomiting, malaise
  • predisposing factors and history of an underlying cause

Examination

  • tachycardia, hypotension, shock
  • altered mental state
  • jaundice (60-70%)

Eponymous findings

  • Charcot triad (50-75% of cases): fever, RUQ pain and jaundice
  • Reynold’s pentad (~5% of cases): Charcot triad plus altered mental state and shock

INVESTIGATIONS

Bedside

  • blood gas including glucose (liver failure, HAGMA, lactate)
  • ECG (myocardial ischaemia)

Laboratory

  • FBC (neutrophilia)
  • UEC (renal failure due to MODS)
  • LFTs (hyperbilirubinaemia is almost always present; hepatitic picture (raised AST, ALT) in addition to obstruction (raised ALP))
  • lipase (co-existent pancreatitis)
  • Coagulation profile (e.g. liver impairment or DIC from overwhelming sepsis)
  • septic screen (take blood cultures before giving antibiotics)

Imaging

  • abdominal ultrasound (evidence of biliary obstruction: CBD dilation is >90%, although the diameter of the CBD becomes a less useful parameter in patients who have previously undergone cholecystectomy, as physiological dilation of the CBD can occur in this setting. Transabdominal ultrasound has a poor sensitivity for detecting mid to distal CBD stones.)
  • CXR (pneumonia, GI perforation)
  • Abdominal CT (if unclear diagnosis)
  • MRCP (if unclear diagnosis)

DIFFERENTIAL DIAGNOSIS

  • biliary leak
  • cholecystitis
  • hepatic abscess
  • Mirizzi syndrome
  • pancreatitis
  • right lower lobe pneumonia
  • infected choledochal cyst
  • recurrent pyogenic cholangitis
  • biliary malignancy

MANAGEMENT

Resuscitation

  • as appropriate using ABC approach
  • treat septic shock

Early antibiotics (<1h of presentation)

  • amoxcillin 1 g IV q6h (child 25 mg/kg up to 1g), AND
    gentamicin 4 to 6 mg/kg  IV, for 1 dose  (<10y: 7.5 mg/kg; >10y: 6 mg/kg) and 1 or 2 further doses at intervals based on renal function
  • If susceptibility results are not available by 72h:
    • change gentamicin to piperacillin/tazobactam or ticarcillin/clavulanate
  • If gentamicin is contraindicated or penicillin sensitivity:
    • ceftriaxone 1 g IV q24h (child: 25 mg/kg up to 1 g) OR 2 cefotaxime 1 g IV q8h (child: 25 mg/kg up to 1 g)
  • If immediate penicillin hypersensitivity seek expert advice.
  • If history of previous biliary tract surgery or known biliary obstruction, need to treat anaerobes:
    • add metronidazole 500 mg IV q12h (child: 12.5 mg/kg up to 500 mg).
  • If unresponsive to initial therapy:
    • piperacillin/tazobactam 4+0.5 g IV q8h (child: 100+12.5 mg/kg up to 4+0.5 g) OR
      ticarcillin/clavulanate 3+0.1 g IV q6h (child: 50+1.7 mg/kg up to 3+0.1 g)
  • After clinical improvement, change to oral therapy.
    • If susceptibility results are not available, use amoxycillin+clavulanate 875+125 mg q12h po (child: 22.5+3.2 mg/kg up to 875+125 mg)
    • For uncomplicated disease, the total course duration is up to 7 days.

Urgent relief of biliary obstruction

  • endoscopic retrograde cholangiopancreatography [ERCP] witihn 24-48h
  • sphincterotomy +/- biliary stone removal
  • PTC (percutaneous transhepatic cholangiography)
  • Ultrasound-guided drainage
  • lithotripsy if stone >2cm
  • open surgical decompression

Definitive treatment of the underlying cause

  • e.g. cholecystectomy, biliary stent

Supportive care and monitoring

Seek and treat complications

  • Biliary obstruction (e.g. serum bilirubin >85 umol/L) may potentiate aminoglycoside nephrotoxicity
  • complications of septic shock
  • complications of procedures (e.g. pancreatitis, haemorrhage)

References and Links

Journal articles

  • Lee JG. Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol. 2009 Sep;6(9):533-41. PMID: 19652653.
  • Mosler P. Management of acute cholangitis. Gastroenterol Hepatol (N Y). 2011 Feb;7(2):121-3. PMC3061017.
  • Wada K, et al. Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007;14(1):52-8. PMC2784515.

CCC 700 6

Critical Care

Compendium

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