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.
Ascending cholangitis, an infective process of the biliary tree, is not to be confused with the autoimmune disorders primary biliary cholangitis (PBC) or primary biliary cirrhosis (PSC).
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Clinical presentation
The classical presentation is Charcot's triad of fever, right upper quadrant abdominal pain, and jaundice, which is only seen in ~40% of patients.
If the patient also presents with hypotension and confusion, then they are said to have Reynold's pentad, which reflects progression of disease 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 causing obstruction of the common bile duct by calculi in 80% of cases.
malignant disease (~20%)
primary sclerosing cholangitis (biliary strictures)
biliary tree procedures or instrumentation, e.g. ERCP
rarely, in the setting of Mirizzi syndrome
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
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. Common bile duct dilatation or radiopaque obstructing stones may be seen. The normal CBD diameter is <6mm 15.
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
organ dysfunction
advanced age >75 years
malignant 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
bacteremia
endotoxemia
elevated serum creatinine
elevated urea/BUN
dilated common bile duct (≥11 mm diameter)
Complications
sepsis
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.
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