Acute cholangitis

Acute cholangitis, or ascending cholangitis, is a form of cholangitis and refers to acute bacterial infection of the biliary tree secondary to bile duct obstruction. It is a condition with high mortality that necessitates emergent biliary decompression. 

Clinical presentation

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 Reynolds pentad, which is the Charcot triad (fever, pain and jaundice) plus shock and delirium (and/or lethargy) ^1-3. 

Pathology

Gram-negative enteric bacteria, most commonly Escherichia coli, are the primary pathogens ³. 

Acute cholangitis is seen in the setting of biliary tree obstruction ^1,2:

• choledocholithiasis (~80causing obstruction of the common bile duct by calculi in 80%) of cases.

• malignancymalignant disease (~20%)

• sclerosing cholangitis

• biliary tree procedures or instrumentation, e.g. ERCP

Radiographic features

Acute cholangitis is typically a clinical diagnosis with imaging performed to determine if there is evidence of ^1,3:

• intrahepatic and/or extrahepatic duct dilatation (indicating obstruction/stasis)

• bile duct wall thickening or focal outpouchings

• cholelithiasis/choledocholithiasis

Ultrasound

A hallmark finding of ascending cholangitis on ultrasound is thickening of the walls of the bile ducts in the appropriate clinical setting ⁴. Ultrasound may also show biliary dilatation with calculi, with or without pus, which appears as debris material within the common bile duct. In the setting of acute cholangitis, sensitivity to detect choledocholithiasis is reduced ^5,6. 

CT 

Inhomogeneous liver enhancement on arterial-phase CT. This is a non-specific sign and should be interpreted in the correct clinical context ^2,7.

Treatment and prognosis

Treatment involves appropriate antibiotic therapy and biliary tree decompression (usually either via ERCP or PTC). Mortality rates are between 50-90% for severe acute cholangitis ^8,9.

Various factors suggestive of poor prognosis include ^5,10-12:

• high fever >39°C

• shock

• organ dysfunction

• advanced age >75 years

• mental confusion

• malignancy as aetiology

• medical comorbidities

• hyperbilirubinaemia ≥2.2 mg/dL

• reduced platelet count <150 × 10⁹/L

• hypoalbuminaemia <3.0 mg/dL

• prolonged prothrombin time >1.5 s

• leucocytosis >20,000/mm³

• bacteraemia

• endotoxemia

• elevated serum creatinine

• elevated urea/BUN

• dilated common bile duct (≥11 mm diameter)

• bile duct stones

• liver abscesses

Complications

• hepatic abscess

• portal vein thrombosis

• sepsis, and

• biliary peritonitis.

History and etymology

Jean-Martin Charcot (1825-1893) was trained as a pathologist, but he was also a skilled practicing physician, and for many the "father of neurology", who also made important contributions to psychiatry. He also has the distinction of probably having more medical eponyms named after him than any other individual in history ^13,14.