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.
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:
- Gallstones (Choledocholithiasis) – accounts for ~80% of cases
- Sclerosing cholangitis
- Chronic pancreatitis
- Gallbladder cancer
- Pancreatic cancer
Common causative organisms include:
- E. coli (25-50%)
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.
A typical presentation includes Charcot’s triad, which consists of:
- Right upper quadrant pain
- Fluctuating jaundice
- 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:
- Pruritus secondary to hyperbilirubinaemia
- Pale stools/steatorrhoea
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.
|Full Blood Count||Raised white blood cell count and decreased platelet count commonly seen|
|Urea and Electrolytes||Raised serum urea, raised creatinine, decreased potassium and decreased magnesium will help assess severity of organ dysfunction and fluid status|
|Serum Amylase or Lipase||If elevated above 3x normal amounts, suggests acute pancreatitis. Both biomarkers offer similar diagnostic accuracy but lipase is more preferable to amylase as it remains elevated for longer.|
|Arterial Blood Gas||Low bicarbonate, raised lactate and metabolic acidosis will help assess severity of organ dysfunction and fluid status|
|Liver Function Test||High bilirubin, high transaminase, high alkaline phosphatase may indicate liver organ dysfunction as a consequence of cholestasis|
|CRP and ESR||Elevated levels indicates inflammation and infection|
|Blood Cultures||Can identify infective organisms, usually Gram negative organisms.|
|Coagulation and Clotting function||Raised prothrombin time in sepsis, may indicate disseminated intravascular coagulation.|
|Transabdominal Ultrasound||Can detect dilation and obstruction by gallstones in the common bile duct.|
|Endoscopic Retrograde Cholangiopancreatography (ERCP)||First line intervention for patients with history of biliary disease or predisposing factors. Through observation of the bile duct, it can diagnose and extract biliary stone causing obstruction.|
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.
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.
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 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.
Intravenous opioids, such as morphine and fentanyl, are commonly used for pain management.
Ascending cholangitis and its treatments have associated complications, including:
- Acute pancreatitis
- Hepatic abscess
- Failure to drain with intervention
Mortality of ascending cholangitis is ~10%.