CHOLANGITIS 

Cholangitis is an infection and inflammation of the biliary tract, usually caused by bacterial infection occurring in the presence of biliary obstruction.

It is a potentially life-threatening condition requiring early antibiotics and biliary drainage when obstruction is present.

Common Causes

Biliary obstruction

• Choledocholithiasis – most common cause
• Biliary strictures
• Pancreatic or biliary tumors
• Primary sclerosing cholangitis
• Post-operative biliary injury
• Parasitic infestation

Iatrogenic causes

• ERCP
• Biliary stent obstruction
• Biliary instrumentation

Common Causative Organisms

Usually Gram-negative enteric bacteria:

• Escherichia coli
• Klebsiella species
• Enterobacter species

Other organisms:

• Enterococcus
• Streptococcus
• Anaerobes, especially in severe or complicated infection

Pathophysiology

Biliary obstruction

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Increased intrabiliary pressure

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Bacterial migration/colonization

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Inflammation of bile ducts

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Bacteraemia and systemic inflammatory response

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Sepsis ± septic shock

Clinical Features

Classic Charcot’s Triad

1. Fever
2. Right upper quadrant abdominal pain
3. Jaundice

Severe disease — Reynolds’ Pentad

Charcot’s triad +

4. Hypotension

5. Altered mental status

Reynolds’ pentad suggests severe cholangitis with sepsis.

Other Symptoms

• Chills/rigors
• Nausea and vomiting
• Malaise
• Dark urine
• Pale stools
• Pruritus
• Loss of appetite

Investigations

Blood tests

• FBC: leukocytosis
• CRP: elevated
• LFTs: raised bilirubin, ALP and GGT
• AST/ALT may also be elevated
• Urea, creatinine and electrolytes
• Blood cultures before antibiotics if this does not delay treatment
• Lactate in suspected sepsis

Imaging

Ultrasound

• Bile duct dilatation
• Gallstones
• Possible obstruction

MRCP

• Detailed assessment of the biliary tree
• Helps identify the level and cause of obstruction

ERCP

• Mainly therapeutic
• Allows biliary drainage and stone removal/stenting

Diagnosis

Diagnosis is based on a combination of:

• Systemic inflammation
• Cholestasis
• Imaging evidence of biliary obstruction/inflammation

Think of cholangitis when a patient has:

Fever + jaundice + RUQ pain ± evidence of biliary obstruction.

Management

Cholangitis is a medical emergency, particularly when associated with sepsis.

A. Initial management

• ABC assessment
• Oxygen if hypoxaemic
• IV access
• IV fluids
• Monitor vital signs and urine output
• Take blood cultures
• Start broad-spectrum IV antibiotics
• Analgesia and antiemetics as required

B. Antibiotics

Choice depends on local guidelines and severity.

Examples include:

• Ceftriaxone + metronidazole
• Piperacillin-tazobactam
• Cefepime + metronidazole
• Other appropriate broad-spectrum regimens based on local resistance patterns

C. Relieve obstruction

Biliary drainage is essential when there is persistent obstruction or severe disease.

Preferred method:

• ERCP

ERCP can:

• Remove common bile duct stones
• Perform sphincterotomy
• Insert a biliary stent
• Establish biliary drainage

If ERCP is unsuccessful or unavailable:

• Percutaneous transhepatic biliary drainage
• Surgical drainage in selected cases

Complications

Untreated cholangitis can cause:

• Sepsis
• Septic shock
• Liver abscess
• Acute kidney injury
• Respiratory failure
• Multiorgan failure
• Biliary cirrhosis with recurrent disease
• Death

Cholangitis vs Cholecystitis

Key Exam Points 

• Most common cause: Common bile duct stone (choledocholithiasis)
• Classic triad: Fever + jaundice + RUQ pain
• Severe cholangitis: Reynolds’ pentad
• Common organism: E. coli
• Important investigation: Ultrasound initially; MRCP for detailed biliary imaging
• ERCP: Important therapeutic procedure for biliary decompression
• Main treatment principles: Resuscitation + antibiotics + biliary drainage
• Cholangitis can rapidly progress to sepsis and septic shock.