Citation, DOI & article data
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 Reynolds pentad, which is Charcot triad plus shock and delirium (and/or lethargy) 1-3.
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 (~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 1,3:
- 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 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.
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
Poor prognostic factors
Various factors from literature to suggest poor prognosis include 5,10-12:
- high fever >39°C
- organ dysfunction
- advanced age >75 years
- mental confusion
- malignancy as etiology
- medical comorbidities
- hyperbilirubinemia ≥2.2 mg/dL
- reduced platelet count <150 × 109/L
- hypoalbuminemia <3.0 mg/dL
- prolonged prothrombin time >1.5 s
- leukocytosis >20,000/mm3
- elevated serum creatinine
- elevated urea/BUN
- dilated common bile duct (≥11 mm diameter)
- bile duct stones
- liver abscesses
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.
- 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. 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
- 3. Emergency Radiology. Springer. (2007) ISBN:3540689087. Read it at Google Books - Find it at Amazon
- 4. 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
- 5. Chi-Leung Liu, Sheung-Tat Fan. Acute cholangitis. (2019) Pubmed
- 6. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. (2016) Journal of hepatology. 65 (1): 146-181. doi:10.1016/j.jhep.2016.03.005 - Pubmed
- 7. 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
- 8. Mosler P. Management of acute cholangitis. Gastroenterol Hepatol (N Y). 2011;7 (2): 121-3. Free text at pubmed - Pubmed citation
- 9. Infections of the Gastrointestinal System. Jaypee Brothers Medical Pub. ISBN:9350903520. Read it at Google Books - Find it at Amazon
- 10. Isogai M, Yamaguchi A, Harada T, et al. Cholangitis score: a scoring system to predict severe cholangitis in gallstone pancreatitis. Journal of Hepato-Biliary-Pancreatic Surgery. 9 (1): 98. doi:10.1007/s005340200010
- 11. Mohammad Alizadeh AH. Cholangitis: Diagnosis, Treatment and Prognosis. (2017) Journal of clinical and translational hepatology. 5 (4): 404-413. doi:10.14218/JCTH.2017.00028 - Pubmed
- 12. Wada K, Takada T, Kawarada Y, et al. Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. (2007) Journal of hepato-biliary-pancreatic surgery. 14 (1): 52-8. doi:10.1007/s00534-006-1156-7 - Pubmed
- 13. Tan SY, Shigaki D. Jean-Martin Charcot (1825-1893): pathologist who shaped modern neurology. (2007) Singapore medical journal. 48 (5): 383-4. Pubmed
- 14. Kumar DR, Aslinia F, Yale SH, et al: the father of neurology. (2011) Clinical medicine & research. 9 (1): 46-9. doi:10.3121/cmr.2009.883 - Pubmed