Ascending Cholangitis

Introduction

Ascending cholangitis is inflammation of the biliary tree (where –cholang– referring to bile vessels and -itis- referring to inflammation). This is commonly due to an infection that occurs with biliary obstruction or malignant strictures as a result of bacteria ascending from the junction within the duodenum.

Most patients will be acutely unwell and can deteriorate quickly and, hence, cases require urgent evaluation and management. Patients are at risk of sepsis with a mortality of 5-10% even when treated with antibiotics.

Causes

Any and all causes of biliary tree strictures can lead to infections. The most common cause is choledocholithiasis, where a stone becomes dislodged from the gallbladder and obstructs the biliary tree downstream. It can also be caused iatrogenically from previous cholecystectomy or endoscopic retrograde cholangiopancreatogram (ERCP) which scars the lumen of the biliary tree and causes a benign stricture. Up to 3% of patients may develop cholangitis after ERCP. Other causes of benign strictures include sclerosing cholangitis and chronic pancreatitis. Malignant strictures are less common and are associated with primary biliary tumours (cholangiocarcinoma), primary gallbladder cancer and pancreatic cancer.

A summary list of causes is:

1. Gallstones (Choledocholithiasis) – accounts for ~80% of cases
2. Post-ERCP
3. Cholecystectomy
4. Sclerosing cholangitis
5. Chronic pancreatitis
6. Cholangiocarcinoma
7. Gallbladder cancer
8. Pancreatic cancer

Causative organisms

Common causative organisms include:

• E. coli (25-50%)
• Klebsiella
• Enterococcus
• Enterobacter

Pathophysiology

Cholangitis requires both biliary stasis and bacterial growth in bile.  Obstruction allows sludge and pressure for bacteria to grow. This eventually produces a pressure gradient for bacteria to enter the bloodstream which will lead to sepsis if untreated.

Clinical features

A typical presentation includes Charcot’s triad, which consists of:

1. Right upper quadrant pain
2. Fluctuating jaundice
3. Swinging fever, usually with rigors

However, it is important to note that many cases of ascending cholangitis do not have all three features of Charcot’s triad. In severe cases, Reynold’s pentad may be present, which includes the addition of hypotension and reduced consciousness to Charcot’s triad.

Other potential clinical features include:

• Haemodynamic instability:
  • Tachycardia
  • Hypotension
• Pruritus secondary to hyperbilirubinaemia
• Pale stools/steatorrhoea

Investigations

Investigations for ascending cholangitis are primarily focussed on blood tests. White blood cells, platelet count and C-reactive protein will reflect the state of inflammation whereas urea and electrolytes are affected by tissue damage and reflect renal function. Arterial blood gas is taken to measure blood pH and lactate as part of sepsis investigation. Imaging will help identify and, potentially treat, causes such as gallstones.

Blood tests

Imaging

Management

Diagnosis relies on a combination of:

• Systemic inflammation: fever, leucocytosis
• Cholestasis: jaundice, abnormal LFTs
• Imaging: biliary dilation and/or evidence of obstruction

Initially, patients should be managed with IV fluids and antibiotics; antibiotics should be broad-spectrum until pathogen is identified on blood cultures eg. co-amoxiclav, ciprofloxacin. If patients fail to respond to antibiotics and there are signs of septic shock, biliary decompression with ERCP should be performed. After the acute episode resolves, patients may have cholecystectomy or other specialist follow-up depending on the cause.

Fluid therapy

Patient’s pulse, blood pressure and fluid status should be assessed. Intravenous fluids, such as crystalloids, should be given if haemodynamically compromised. Start with fluid bolus and then reassess to guide further fluid therapy. Urinary catheters should also be inserted to monitor urine output, kidney function and guide fluid therapy.

Antibiotics

Patients presenting with an infective picture should be started on empirical antibiotics as soon as possible. Take blood culture first if possible, however, do not delay administration of antibiotics for it. Antibiotics regime can be adjusted with the guidance of blood culture sensitivity afterwards.

Biliary decompression

Biliary decompression and drainage may be necessary for patients who are deteriorating despite antibiotics and intensive medical management. Options include ERCP, sphincterotomy, stents placement, endoscopic lithotripsy, percutaneous trans-hepatic cholangiography (PTC), laparoscopy and laparotomy.

Analgesics

Intravenous opioids, such as morphine and fentanyl, are commonly used for pain management.

Complications

Ascending cholangitis and its treatments have associated complications, including:

• Acute pancreatitis
• Hepatic abscess
• Failure to drain with intervention

Prognosis

Mortality of ascending cholangitis is ~10%.

References

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5823698/
• https://bestpractice.bmj.com/topics/en-gb/3000149/
• https://teachmesurgery.com/hpb/gall-bladder/cholangitis/
• https://geekymedics.com/cholangitis/