Acute cholangitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Key Recommendations

Acute cholangitis is an emergency that requires prompt diagnosis and treatment.[22] Diagnosis is based on typical history and laboratory findings and confirmed by imaging, endoscopic retrograde cholangiopancreatography (ERCP), or endoscopic ultrasound-guided biliary drainage (EUS-BD) or percutaneous transhepatic biliary drainage if ERCP is unsuccessful.

Most patients will present with fever, jaundice, and right upper quadrant (RUQ) pain (Charcot triad), although some patients with a significant infection may have a surprisingly benign appearance overall.[3] Patients with acute cholangitis typically have diffuse RUQ pain and not classic Murphy sign.

Acute deterioration

Acute cholangitis can quickly become an acute, septic, life-threatening infection if not identified and treated promptly. Consider sepsis if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[23]

The patient with sepsis may present with nonspecific or nonlocalized symptoms (e.g., acutely unwell with a normal temperature) or there may be severe signs with evidence of multiorgan dysfunction and shock.[23] Sepsis represents the severe, life-threatening end of infection.

It is important to use systematic evaluation and recording of vital signs, alongside your clinical judgment, to assess the risk of deterioration due to sepsis.[23]

Treatment should be started immediately if a senior clinical decision-maker makes a diagnosis of suspected sepsis.[24] Local protocols should be followed for the investigation and treatment of all patients with suspected sepsis, or those at risk of deterioration to sepsis.[24][25][26]

For more detail on when to suspect sepsis and on its management, see Sepsis in adults.

History and physical exam

Risk factors for acute cholangitis may be present, most notably:[11]

Older age (average age 50-60 years)[9][16]
Known cholelithiasis
Underlying pancreaticobiliary disease (e.g., biliary strictures, primary or secondary sclerosing cholangitis)
Prior ERCP
Surgical or radiologic biliary tree intervention
HIV infection.

Most patients will present with Charcot triad (fever, jaundice, and RUQ pain).

Fever and RUQ pain are present in 65% to 90% of patients, though fever can be absent in older patients (those over 60 years old). About 65% of patients will have RUQ tenderness.[1] Jaundice is present in 60% to 70% of patients.[1]

Other features may include:

Pale/putty/clay colored stools due to deficient bile secretion to the small intestine.
Pruritis (sensation of itch) associated with any liver disease.
Hypotension, which is present in 30% of patients.[1]
Mental status changes, which occur in about 15% of patients. Hypotension and mental status changes are indicative of severe disease and are associated with a poor prognosis.[1][27] When Charcot triad is associated with these features, it is referred to as Reynolds pentad.

Laboratory tests

Patients with suspected or known acute cholangitis should have the following tests done on admission (listed with common findings):

CBC: white blood cell count is typically >10,000/microliter (reference range 4800-10,800/microliter).
CRP (a marker of inflammation): can be elevated.
LFTs: hyperbilirubinemia is almost always present and, if absent, cholangitis is less likely to be the true diagnosis. Abnormal liver tests are usual findings, with elevated serum alkaline phosphatase and transaminases being typical.
BUN and creatinine: elevated renal function parameters are more common in severe disease states.
Electrolytes plus magnesium: possible decreases of serum potassium and magnesium.
Blood culture: positive blood culture rates among patients with acute cholangitis range from 21% to 71%.[28] Bacteria are usually gram-negative, but gram-positive bacteria and anaerobes are also implicated in cholangitis.[28]

If sepsis is suspected, the following tests should also be ordered:

Coagulation profile: abnormalities can include decreased platelets and elevated prothrombin time.
Blood gas analysis and lactate: metabolic acidosis is common in severe disease states; raised lactate is associated with sepsis.

Venepuncture and phlebotomy: animated demonstration

How to take a venous blood sample from the antecubital fossa using a vacuum needle.

Transabdominal ultrasound and endoscopy

All patients presenting with RUQ pain and suspected cholangitis should undergo transabdominal ultrasound in the first instance.[30][31]

The main value of a transabdominal ultrasound is in detecting cholecystitis, which can mimic cholangitis, and to provide a limited evaluation of the biliary tree.
Transabdominal ultrasound is a quick, easy, and inexpensive initial diagnostic imaging modality. Its accuracy for detecting common bile duct (CBD) dilation is >90%, although the diameter of the CBD becomes a less useful parameter in patients who have previously undergone cholecystectomy (as physiologic dilation of the CBD can occur in this setting).
Transabdominal ultrasound has a poor sensitivity for detecting mid to distal CBD stones.[1]

Patients with a history of biliary disease, an indwelling biliary prosthesis, or other predisposing factors should be considered for early ERCP for rapid diagnosis and therapy. [Figure caption and citation for the preceding image starts]: Endoscopic retrograde cholangiopancreatography reveals a large common bile duct (CBD) stone (arrow) in the mid-common bile ductFrom the collection of Douglas G. Adler; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: Endoscopic photo of same patient following removal of large common bile duct (CBD) stone; note copious pus draining through the ampullaFrom the collection of Douglas G. Adler; used with permission [Citation ends].

Subsequent imaging studies

If there is high clinical suspicion of cholangitis, and transabdominal ultrasound is negative, an abdominal computed tomography (CT) scan with intravenous contrast can be considered.[31]

Abdominal CT provides better anatomical detail of the biliary tree than transabdominal ultrasound. It is particularly useful to visualize the distal part of the CBD.
If neoplasm is suspected as the cause of cholangitis, abdominal CT is a better initial imaging choice than transabdominal ultrasound.
CT scans are contraindicated in patients with intravenous contrast dye allergy and may be detrimental to those with renal dysfunction.

Magnetic resonance cholangiopancreatography (MRCP) is an excellent noninvasive magnetic resonance imaging (MRI) modality with good sensitivity and specificity for the diagnosis of biliary obstruction. It should be ordered if ultrasound and CT are negative and a high clinical suspicion remains for cholangitis.[30][31]

MRCP can provide cholangiograms and pancreatograms and can identify biliary stones, strictures, and/or pancreatic and biliary malignancies with a high sensitivity and specificity. It can also sometimes diagnose cholangitis based on the appearance of the bile duct walls.
MRCP can be particularly informative if there are confounding factors (e.g., underlying liver disease) that could lead to fever, RUQ pain, and jaundice.
MRI scans are contraindicated in some patients with metallic bioimplants.
While MRCP is diagnostically valuable, all patients with cholangitis will ultimately require biliary decompression, most commonly via ERCP. MRCP should thus not be viewed as a requisite study in patients with suspected cholangitis, but is often a helpful tool in determining an etiology and planning for definitive therapy.

Endoscopic ultrasound (EUS) is as accurate as MRCP for the detection of choledocholithiasis.[32] It should be performed if there is suspicion of a CBD stricture or stone that has not been already seen on ultrasound or MRCP.[30] It can also be used if other imaging modalities are unsuitable for the patient.

If EUS is positive for CBD stones, ERCP can often be performed concomitantly. EUS can also facilitate biliary decompression via EUS-BD, if available.[33][34]

Surgical approaches

Surgery should be utilized for diagnostic purposes only when other modalities have failed to identify biliary stone(s) and/ or site(s) of obstruction, or when those modalities are not available, are not feasible, or are contraindicated. In practice, surgery is rarely required for diagnosis or treatment of cholangitis as less invasive approaches are almost always adequate.

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