Acute Cholangitis

What is acute cholangitis?

Acute cholangitis is an infection of the biliary tract that occurs secondary to biliary obstruction, most commonly from choledocholithiasis, resulting in bacterial proliferation and inflammation of the common bile duct.

What is the most common cause of acute cholangitis?

Choledocholithiasis causing obstruction of the common bile duct.

What is the pathophysiology of acute cholangitis?

Obstruction of bile flow increases intraductal pressure, allowing bacterial ascent from the duodenum into the biliary tree, resulting in infection and inflammation.

What organisms commonly cause acute cholangitis?

• Escherichia coli

• Klebsiella species

• Enterococcus species

• Enterobacter species

What are risk factors for acute cholangitis?

• Choledocholithiasis

• Biliary strictures

• Biliary tumors

• Prior biliary procedures

• Primary sclerosing cholangitis

• Primary biliary cholangitis

What are the classic symptoms of acute cholangitis?

• Fever

• Jaundice

• Right upper quadrant abdominal pain

What is Charcot's triad?

• Fever

• Jaundice

• Right upper quadrant pain

Why is Charcot's triad important?

It is the classic clinical presentation of acute cholangitis and should raise concern for biliary tract infection.

What is Reynold's pentad?

• Fever

• Jaundice

• Right upper quadrant pain

• Altered mental status

• Sepsis/shock

What does Reynold's pentad indicate?

Severe acute cholangitis with systemic infection and a higher risk of morbidity and mortality.

What physical examination findings may be present in acute cholangitis?

• RUQ tenderness

• Positive Murphy sign

• Scleral icterus

• Jaundice

• Fever

What is scleral icterus?

Yellow discoloration of the sclera caused by elevated serum bilirubin levels.

What is jaundice?

Yellow discoloration of the skin and mucous membranes caused by hyperbilirubinemia.

What laboratory studies should be obtained when evaluating suspected acute cholangitis?

• CBC with differential

• CMP with liver function tests

• Amylase and lipase

• PT/INR

• Urinalysis

• Blood cultures

• Hepatitis panel

• GGT

Why is a CBC obtained in suspected acute cholangitis?

To evaluate for leukocytosis and evidence of infection.

Why are blood cultures obtained in acute cholangitis?

To identify causative organisms and guide antibiotic therapy.

Why are amylase and lipase obtained in patients with suspected biliary disease?

To evaluate for concurrent pancreatitis.

Which liver function tests are commonly elevated in acute cholangitis?

• Alkaline phosphatase

• Bilirubin

• AST

• ALT

• GGT

What laboratory pattern is most suggestive of biliary obstruction?

Elevated *alkaline phosphatase, GGT, and direct bilirubin.

What imaging study is typically the initial test for suspected acute cholangitis?

Right upper quadrant ultrasound.

What findings may be seen on ultrasound in biliary obstruction?

• Gallstones

• Common bile duct dilation

• Biliary sludge

• Evidence of obstruction

When may CT abdomen be useful in biliary disease?

CT can evaluate complications or alternative abdominal pathology when ultrasound findings are inconclusive.

What is MRCP?

Magnetic resonance cholangiopancreatography is a noninvasive imaging study used to visualize the biliary and pancreatic ducts.

When is MRCP useful?

When additional evaluation of the biliary tree is needed after initial imaging.

What is ERCP?

Endoscopic retrograde cholangiopancreatography is an endoscopic procedure used to diagnose and treat biliary obstruction.

Why is ERCP important in acute cholangitis?

ERCP allows both diagnosis and therapeutic biliary decompression.

What are the therapeutic benefits of ERCP?

• Stone extraction

• Sphincterotomy

• Stent placement

• Biliary drainage

What are the three major categories of jaundice?

• Prehepatic

• Intrahepatic

• Posthepatic

What causes prehepatic jaundice?

Conditions that increase bilirubin production before hepatic processing, most commonly hemolysis.

What type of bilirubin is elevated in prehepatic jaundice?

Indirect (unconjugated) bilirubin.

What are common causes of prehepatic jaundice?

• Hemolysis

• Hemolytic anemia

• Increased red blood cell destruction

What causes intrahepatic jaundice?

Diseases affecting hepatocytes or the intrahepatic biliary ductal system.

What bilirubin pattern is typically seen in intrahepatic jaundice?

Mixed or either direct and indirect hyperbilirubinemia.

What are common causes of intrahepatic jaundice?

• Viral hepatitis

• Alcoholic hepatitis

• Toxic liver injury

• Gilbert syndrome

• Crigler-Najjar syndrome

• Intrahepatic cholestasis

• Cirrhosis

What causes posthepatic jaundice?

Obstruction of bile flow in the extrahepatic biliary tree.

What type of bilirubin is elevated in posthepatic jaundice?

Direct (conjugated) bilirubin.

What are common causes of posthepatic jaundice?

• Choledocholithiasis

• Cholangiocarcinoma

• Primary biliary cholangitis

• Primary sclerosing cholangitis

• Pancreatic head tumors

• Ampulla of Vater tumors

What type of jaundice is associated with acute cholangitis?

Posthepatic (obstructive) jaundice.

What are the goals of treatment in acute cholangitis?

• Control infection

• Relieve biliary obstruction

• Prevent sepsis

• Restore biliary drainage

What supportive measures are used in acute cholangitis?

• Hospital admission

• IV fluids

• Pain control

• Electrolyte management

What is the initial antibiotic approach in acute cholangitis?

Broad-spectrum antibiotics are started empirically and later tailored to culture results.

Why are antibiotics alone often insufficient in acute cholangitis?

Persistent biliary obstruction must be relieved to achieve definitive treatment.

What is biliary drainage?

Removal of obstructed bile to restore flow and eliminate the source of infection.

What is the preferred method of biliary drainage in acute cholangitis?

ERCP with sphincterotomy, stone extraction, or stent placement.

What is percutaneous transhepatic biliary drainage?

A procedure that drains bile through a catheter inserted through the liver when ERCP cannot be performed.

When is surgical drainage considered for acute cholangitis?

When endoscopic or percutaneous approaches are unsuccessful or contraindicated.

What complications can occur if acute cholangitis is untreated?

• Sepsis

• Septic shock

• Liver abscess

• Multi-organ failure

• Death

What is the most important clinical pearl for acute cholangitis?

Fever, jaundice, and right upper quadrant pain together should immediately suggest Charcot's triad and acute cholangitis.

What is the most important management principle in acute cholangitis?

Antibiotics plus biliary decompression are required for definitive treatment.

What board-style association is commonly tested with acute cholangitis?

Charcot's triad = fever + jaundice + RUQ pain

What is choledocholithiasis?

The presence of gallstones within the common bile duct causing partial or complete biliary obstruction.

Why does choledocholithiasis commonly lead to acute cholangitis?

Obstruction of bile flow promotes bacterial growth and ascending infection within the biliary tree.

What is the difference between cholecystitis and cholangitis?

Cholecystitis is inflammation of the gallbladder, whereas cholangitis is infection of the biliary tree, usually involving the common bile duct.

What is the classic laboratory finding of obstructive jaundice?

Elevated direct bilirubin, alkaline phosphatase, and GGT.

Why is GGT useful when evaluating elevated alkaline phosphatase?

GGT helps confirm a hepatobiliary source because alkaline phosphatase can also originate from bone.

What is the most common cause of posthepatic jaundice?

Choledocholithiasis.

What is the most common imaging finding in common bile duct obstruction?

Dilatation of the common bile duct.

What is the difference between MRCP and ERCP?

MRCP is a noninvasive diagnostic imaging study, whereas ERCP is both diagnostic and therapeutic.

Which procedure is preferred when biliary obstruction requires treatment?

ERCP.

What are indications for urgent ERCP in acute cholangitis?

• Persistent biliary obstruction

• Ascending cholangitis

• Sepsis

• Clinical deterioration despite antibiotics

What is ascending cholangitis?

Infection that develops when bacteria ascend from the duodenum into an obstructed biliary system.

What bacteria are most commonly isolated in acute cholangitis?

• Escherichia coli

• Klebsiella species

• Enterococcus species

Why is biliary obstruction considered a medical emergency when infection is present?

Obstruction prevents adequate drainage, allowing rapid progression to bacteremia, sepsis, and septic shock.

What is the mortality risk of untreated acute cholangitis?

Untreated disease can rapidly progress to life-threatening sepsis and multi-organ failure.

What physical exam finding is classically associated with gallbladder inflammation?

Murphy sign — inspiratory arrest during palpation of the right upper quadrant.

What is Murphy sign?

Increased pain and inspiratory arrest when the examiner palpates the gallbladder during inspiration.

How does bilirubin metabolism relate to jaundice classification?

• Prehepatic causes increase indirect bilirubin production

• Intrahepatic causes impair bilirubin processing

• Posthepatic causes impair excretion of direct bilirubin

What bilirubin level generally produces visible jaundice?

Approximately >2–3 mg/dL total bilirubin.

What are the hallmark findings of Charcot's triad?

• Fever

• Jaundice

• Right upper quadrant pain

What are the hallmark findings of Reynold's pentad?

• Fever

• Jaundice

• Right upper quadrant pain

• Altered mental status

• Hypotension/septic shock