Acute cholangitis

• Definition
  • Bacterial infection of the bile ducts, typically due to biliary obstruction
  • Medical emergency requiring prompt diagnosis and intervention
• Etiology/Pathophysiology
  • Biliary obstruction → bile stasis → bacterial overgrowth → ascending infection
  • Common causes of obstruction:
    • Choledocholithiasis (most common)
    • Biliary strictures (post-surgical, PSC)
    • Malignancy (cholangiocarcinoma, pancreatic cancer)
    • Parasites (Clonorchis sinensis, Ascaris)
  • Common organisms: E. coli, Klebsiella, Enterococcus, Bacteroides
• Clinical Features
  • Charcot’s triad (50-70% of cases):
    • Fever/chills
    • RUQ pain
    • Jaundice
  • Reynolds pentad (severe/suppurative cholangitis):
    • Charcot’s triad + altered mental status + hypotension/septic shock t
  • Other: nausea/vomiting, pruritus
• Diagnostics
  • Labs:
    • ↑ WBC with left shift
    • ↑ Direct bilirubin (conjugated hyperbilirubinemia)
    • ↑ Alkaline phosphatase (cholestatic pattern)
    • ↑ GGT
    • Blood cultures (positive in 20-70%)
  • Imaging:
    • Ultrasound (first-line): dilated bile ducts, stones
    • MRCP or ERCP: visualize biliary tree, identify obstruction level
    • CT: if complications suspected (abscess)
• Treatment
  1. Stabilization & Medical Management:
     • Admit to ICU if Reynolds pentad/septic.
     • Aggressive IVF resuscitation, NPO.
     • Broad-spectrum IV Abx (e.g., Piperacillin-tazobactam OR Ceftriaxone + Metronidazole).
  2. Biliary Decompression:
     • Urgent ERCP w/ sphincterotomy and biliary drainage/stenting (perform within 24 hours; perform emergently if pt is hemodynamically unstable/septic).
     • Percutaneous transhepatic cholangiography (PTC) or surgical decompression if ERCP fails or is unavailable.
  3. Definitive Treatment:
     • Elective cholecystectomy during the same hospital admission once the acute episode resolves (if etiology is cholelithiasis/choledocholithiasis).
• Complications
  • Septic shock, hepatic abscess, secondary biliary cirrhosis, acute renal failure