Aetiology
The most common aetiology of acute cholangitis is cholelithiasis leading to choledocholithiasis and biliary obstruction.[10] Iatrogenic biliary duct injury, most commonly caused via surgical injury during cholecystectomy, can lead to benign strictures, which can in turn lead to obstruction (with or without secondary sclerosing cholangitis).[10][12] Other causes of benign biliary stricture include chronic pancreatitis (with stenosis and stricture of the distal common bile duct, which has an intrapancreatic course), radiation-induced biliary injury, or biliary injury as a complication of systemic chemotherapy (e.g., fluorodeoxyuridine).[12][13]
Sclerosing cholangitis (primary and secondary) causes up to 24% of cases of acute cholangitis.[14] Less common causes of acute cholangitis are acute pancreatitis, parasite entry into the bile ducts (Ascaris lumbricoides or Fasciola hepatica), extrinsic compression of the biliary tree due to adenopathy, fibrosis of the papilla, blood clots, and sump syndrome (a rare complication that can develop following the creation of a choledochoduodenostomy where the distal common bile duct can trap food particles and become a source of biliary infection).[13]
Malignant strictures are much less likely to be associated with the development of acute cholangitis, but this can still occur, especially if there has been prior instrumentation of the biliary tree. Malignant biliary strictures most commonly arise due to primary biliary tumours (cholangiocarcinoma), primary gallbladder cancer, ampullary cancer, pancreatic cancer, and, rarely, primary small bowel cancer.[13]
Pathophysiology
Obstruction of the common bile duct initially results in bacterial seeding of the biliary tree, possibly via the portal vein, and when combined with bacterial contamination, can lead to acute cholangitis.[10] Additionally, sludge forms, providing a growth medium for the bacteria. As the obstruction progresses, the bile duct pressure increases. This forms a pressure gradient that promotes extravasation of bacteria into the bloodstream.[10] If not recognised and treated, this will lead to sepsis.[10][15]
Classification
Cholangitis
In 1877, Charcot was the first to describe the triad of right upper quadrant (RUQ) pain, fever, and jaundice as a result of biliary obstruction and bacterial growth in the biliary tree.
Cholangitis with sepsis
A more severe form of cholangitis, resulting in the Charcot's triad plus evidence of sepsis. Hypotension, shock (hypotension and organ dysfunction), and mental status changes may accompany cholangitis with sepsis. These findings are a result of increased intraductal pressure from the obstruction, which leads to reflux of bacteria and ultimately to sepsis. It should be noted that the presentation of cholangitis can be variable and many patients early in the course of their disease may present with non-specific RUQ pain and abnormal liver function tests, without florid signs of sepsis.
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