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 that necessitates emergent biliary decompression.
The classical presentation is the Charcot triad of fever, right upper quadrant abdominal pain, and jaundice, which is only seen in ~40% of patients. Patients can also present with Reynold pentad, which is Charcot triad with shock and altered mental status 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 performed 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 calculi, with or without pus, which appears as debris material within the common bile duct.
Inhomogeneous liver enhancement on arterial-phase CT. This is a non-specific sign 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