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Acute cholangitis

Dr Mohamed Saber and Dr Henry Knipe et al.

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 delirium 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:

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

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 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 from literature to suggest poor prognosis include 5,10-12:

  • high fever >39°C
  • shock
  • 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
  • bacteremia
  • endotoxemia
  • elevated serum creatinine
  • elevated blood urea nitrate
  • dilated bile duct (≥11 mm diameter)
  • bile duct stones
  • liver abscesses

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 for him than any other individual in history 13,14.

Gallbladder and biliary tract pathology

Article information

rID: 39066
Synonyms or Alternate Spellings:
  • Obstructive cholangitis
  • Bacterial acute cholangitis (BAC)
  • Bacterial cholangitis
  • Ascending cholangitis

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Cases and figures

  • Case 1
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  • Case 2: Ultrasound
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