Acute cholangitis, or ascending cholangitis, is a form of cholangitis and refers to the acute bacterial infection of the biliary tree. It is a condition with high mortality and emergent biliary decompression is required.
The classical presentation is Charcot triad of fever, right upper quadrant abdominal pain, and jaundice, which is seen in ~40%. Patients can also present with Reynold pentad, which is Charcot triad with shock and lethargy/confusion 1,3,4.
Gram-negative enteric bacteria, most commonly Escherichia coli, are the primary pathogens 4.
Acute cholangitis is seen in the setting of biliary tree obstruction 1,3:
- choledocholithiasis (~80%)
- malignancy (~20%)
- sclerosing cholangitis
- biliary tree procedures, e.g. ERCP
Acute cholangitis is typically a clinical diagnosis with imaging to determine if there is evidence of 1,4:
- intrahepatic and/or extrahepatic duct dilatation (indicating obstruction/stasis)
- bile duct wall thickening or focal outpouchings
A hallmark finding of ascending cholangitis on ultrasound is thickening of the walls of the bile ducts in the appropriate clinical setting. Ultrasound may also show biliary dilatation with stones +/- pus - debris material within the common bile duct.
- inhomogeneous liver enhancement on arterial-phase CT (but this is non-specific and should be interpreted in the correct clinical context) 2,3
Treatment and prognosis
- 1. Catalano OA, Sahani DV, Forcione DG et-al. Biliary infections: spectrum of imaging findings and management. Radiographics. 2009;29 (7): 2059-80. doi:10.1148/rg.297095051 - Pubmed citation
- 2. Arai K, Kawai K, Kohda W et-al. Dynamic CT of acute cholangitis: early inhomogeneous enhancement of the liver. AJR Am J Roentgenol. 2003;181 (1): 115-8. doi:10.2214/ajr.181.1.1810115 - Pubmed citation
- 3. Kim SW, Shin HC, Kim HC et-al. Diagnostic performance of multidetector CT for acute cholangitis: evaluation of a CT scoring method. Br J Radiol. 2012;85 (1014): 770-7. doi:10.1259/bjr/72001875 - Free text at pubmed - Pubmed citation
- 4. Emergency Radiology. Springer. (2007) ISBN:3540689087. Read it at Google Books - Find it at Amazon
- 5. Mosler P. Management of acute cholangitis. Gastroenterol Hepatol (N Y). 2011;7 (2): 121-3. Free text at pubmed - Pubmed citation
- 6. Infections of the Gastrointestinal System. Jaypee Brothers Medical Pub. ISBN:9350903520. Read it at Google Books - Find it at Amazon
- 7. Hanbidge AE, Buckler PM, O'Malley ME et-al. From the RSNA refresher courses: imaging evaluation for acute pain in the right upper quadrant. Radiographics. 2004;24 (4): 1117-35. Radiographics (full text) - doi:10.1148/rg.244035149 - Pubmed citation