Cholangitis

Inflammation of the biliary tree

Cause

As with Cholecystitis, cholangitis is usually a complication of gallstones and/or surgery or scoping of the biliary tree. Obstruction of the biliary tree by malignancy can also cause cholangitis.  It can carry significant morbidity/mortality, particularly if it does not respond to antibiotic treatment (toxic cholangitis).

In the UK, the most common infective organisms are Klebsiella spp., E coli, Enterobacter spp., enterococci and streptococci.  Infection may be mixed.  Outside the UK, parasitic infection by roundword and liver fluke can also cause cholangitis.

Presentation

  • Charcot’s triad
    • Fever (90%)
    • RUQ pain and tenderness (70%)
    • Jaundice (60%)
  • Reynaud’s Pentad
    • Charcot’s triad + Hypotension (shock) + Mental confusion
    • Severe disease i.e. affecting one or more of the vital organs
  • Other symptoms include chills/rigors; nausea and vomiting

Investigations

  • Lab tests
    • FBC- Raised WCC; CRP
    • LFTs- Raised Alk Phos and Bilirubin (also may have deranged liver enzymes)
    • Serum Amylase may be raised
    • Blood cultures (positive in around 50%)
    • U&Es- any associated kidney failure
  • Imaging
    • USS and/or MRCP and/or CT
      • Biliary dilation
      • Evidence of stricture/tumour/stones etc
  • Drainage for culture (if done)

Diagnosis

  1. Systemic Inflammation
    1. Fever/chills/rigor
    2. Lab info- raised WCC/CRP
  2. Cholestasis
    1. Jaundice
    2. Lab info- deranged LFTs
  3. Imaging
    1. Biliary dilation
    2. Evidence of underlying cause
  • Suspect diagnosis if there is one point in 1. and one in either 2 or 3.
  • Definite diagnosis if one from all 1, 2 and 3.

Management

  • Fluid resuscitation
    • Resuscitation may be required for those patients in shock
    • ABCDE approach- manage any hypotension, tachycardia etc first
  • Correct any coagulopathy (if necessary and possible)
  • IV antibiotics (Amoxicillin and Metronidazole- consult local formulary)
  • Endoscopic biliary drainage is recommended

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