para>Gallstone risk increases during pregnancy due to biliary cholesterol supersaturation and decreased GB motility.
GENERAL PREVENTION
- Adequate physical activity
- Avoid foods rich in saturated fats.
- In patients with increased risk of biliary stasis: Rapid weight loss, long-term somatostatin therapy or parenteral nutrition, and use of ursodeoxycholic acid reduces lithogenicity.
- Long-term statin use reduces biliary cholesterol concentration of bile and lowers risk of gallstone formation (not recommended for routine prevention).
- Ensure patency of biliary tree with intraoperative cholangiography at time of cholecystectomy; if operative view is not possible and CBD stone is suspected, endoscopic cholangiogram is recommended.
- Prophylactic antibiotics before ERCP
COMMONLY ASSOCIATED CONDITIONS
- Pancreatitis, acute cholecystitis
- Crohn disease
- HIV/AIDS
- Sepsis
DIAGNOSIS
HISTORY
- Presentation often nonspecific. Classic findings:
- Clinical triad of fever, jaundice, and RUQ pain (Charcot triad)
- Reynolds pentad of fever, jaundice, RUQ pain, mental status changes, and hypotension
- Rarely, nonspecific constitutional complaints (malaise, isolated fever, mental status changes, pruritus)
- RUQ pain present in 65-90% of patients. It is variable from mild to severe and diffuse.
- Pain may be intermittent if stones or sludge ball valve in the CBD causes transient, intermittent obstruction.
- Weight loss and anorexia are common.
- Acholic or hypocholic stools
Geriatric Considerations
Elderly present with atypical symptoms in later stages of disease and often have sudden decompensation. Leukocytosis and fever less common in elderly as well. A high index of suspicion is required.
PHYSICAL EXAM
Physical exam findings can be nonspecific:
- Charcot triad (fever, RUQ pain, and jaundice) rarely present; low sensitivity, high specificity
- Fever (90%), chills, and rigors: often absent in older patients
- RUQ or epigastric tenderness (70%), with or without Murphy sign
- Jaundice (60%)
- Hypotension (30%)
- CNS depression (10-20%)
- Palpable, nontender gallbladder (Courvoisier sign)-rare-necessitates ruling out malignant biliary obstruction
- Stigmata of chronic liver disease
- Mild hepatomegaly
DIFFERENTIAL DIAGNOSIS
- Acute cholecystitis; symptomatic cholelithiasis
- Liver abscess, hepatitis
- Acute pancreatitis
- Perforated duodenal ulcer
- Pelvic inflammatory disease
- Kidney stones, acute pyelonephritis
- Acute mesenteric ischemia
- Abdominal aortic aneurysm rupture
- Right lower lobe pneumonia
- Sepsis
DIAGNOSTIC TESTS & INTERPRETATION
- CBC: elevated WBC, neutrophil predominance
- Liver enzymes typically demonstrate a cholestatic pattern: elevated direct bilirubin, alkaline phosphatase, γ-glutamyl transpeptidase. Mild elevation in transaminases (generally <400 IU/L; rarely increase acutely >2,000 IU/L). Hepatocellular disease in acute CBD stone impaction or liver microabscess formation (with subsequent sharp enzyme decline) (2)[A]. Serum amylase and lipase may be elevated without pancreatic disease.
- Blood cultures: positive in 21-71%. Bacteria are usually gram negative; >1 organism in 70% of bile cultures.
- WBC ≥20,000 and total bilirubin ≥10 mg/dL predict poor outcomes.
- Prothrombin time (PT) and partial thromboplastin time (PTT) assess chronic liver disease or disseminated intravascular coagulopathy
- C-reactive protein and erythrocyte sedimentation rate usually elevated.
Diagnostic Procedures/Other
- Initial imaging study: Transabdominal ultrasound (TUS) is preferred initial study; sensitive for gallbladder stones, less so for CBD stones. Normal sonogram does not rule out ascending cholangitis.
- CT for patients with RUQ pain, jaundice, and fever. CT is superior to TUS for visualizing the distal CBD and detecting neoplasms. Contrast CT with helical cholangiography has high sensitivity and specificity for gallstones.
- Magnetic resonance cholangiopancreatography (MRCP) is another noninvasive method to image the biliary tree. MRCP has a high specificity for PSC. Obtain if TUS and CT are negative and suspicion of biliary disease remains.
- ERCP: most definitive (and most invasive) diagnostic test. ERCP permits therapeutic intervention such as biliary sphincterotomy, stone extraction, or stent placement. ERCP preferred if persistent abdominal pain, mental status changes, fever >39 °C, and refractory hypotension despite antibiotics (3).
- Open bile duct or laparoscopic surgery may be superior to ERCP for clearance of bile ducts (4)[A].
- Endoscopic ultrasound (EUS) helps differentiate neoplasms from inflammatory periampullary masses.
- Percutaneous transhepatic cholangiography (PTC) is useful only if ERCP is unavailable; allows for biliary stone extraction and stenting
TREATMENT
- Monitor airway, breathing, hydration, circulation, and resuscitate as needed; IV crystalloid
- NPO; nasogastric tube for vomiting
- Medical treatment is effective in 80% for symptom control. Operative clearance of obstruction is curative.
GENERAL MEASURES
- Fluid resuscitation; empiric antibiotics after blood cultures drawn; correct electrolyte abnormalities and coagulopathies
- NG tube, Foley catheter, and NPO
- Up to 80% respond to antibiotics and conservative management followed by biliary drainage-timing of surgery depends on clinical stability.
- 20% of patients require urgent (24 to 48 hours) biliary decompression.
- Indications for urgent decompression include persistent abdominal pain, mental status changes, fever >102.2 °F (>39 °C), and refractory hypotension.
MEDICATION
Management consists of IV antibiotics, fluid resuscitation, oxygen supplementation, correction of coagulopathy, and definitive biliary drainage (1,3).
- Initial empiric broad-spectrum antibiotics until results of blood and bile cultures are obtained. Refine therapy when sensitivities are available (5)[A].
- Antibiotics in mild disease for 5 to 7 days. If blood culture positive, treat for 10 to 14 days.
- Once biliary drainage is achieved and patients are improved clinically, switch to oral antibiotics (6)[A].
- Potential broad-spectrum regimens include:
- Monotherapy with a β-lactam/β-lactamase inhibitor, such as ampicillin-sulbactam (3 g q6h) OR piperacillin/tazobactam (4.5 g q6h) OR ticarcillin-clavulanate (3.1 g q4h)
- Metronidazole (500 mg IV q8h) with a 3rd-generation cephalosporin, such as ceftriaxone (1 g q12h)
- Metronidazole (500 mg IV q8h) with a fluoroquinolone (ciprofloxacin 400 mg IV q12h or levofloxacin 500 mg IV daily)
- Monotherapy with meropenem (1 g q6h)
SURGERY/OTHER PROCEDURES
Relief of obstruction is definitive:
- For high-risk patients, decompression by ERCP allows for endoscopic sphincterotomy, stone extraction, or biliary stenting.
- Secondary options include surgery with intraoperative cholangiography (IOC). Controversy exists concerning routine IOC in all patients undergoing laparoscopic cholecystectomy.
- Interval cholecystectomy for CBD-related cholangitis after stabilization and in gallstone pancreatitis
- Prophylactic antibiotics are indicated for invasive procedures.
INPATIENT CONSIDERATIONS
- ICU admission for ill patients
- Increased risk of mortality in patients with acute renal failure, liver abscess or cirrhosis, cholangitis due to high malignant biliary stricture, or post-PTC, female gender, and age greater than 50 years.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patients with recurrent symptoms of cholangitis may require maintenance antibiotics and more advanced imaging to exclude liver abscess or residual stones.
DIET
NPO initially. Gradual return to normal diet. Low-fat diet to reduce biliary activity.
PATIENT EDUCATION
National Digestive Diseases Information Clearinghouse, Box NDDIC, Bethesda, MD 20892; 301-468-6344.
PROGNOSIS
- Most patients improve quickly after intervention.
- In absence of significant comorbidities and if clinically stable on presentation, mortality is <5%. Patients presenting with Reynold pentad have mortality rates as high as 50%.
- Malignancy, coexistent cardiac or renal impairment, and hepatic abscesses worsen prognosis. Comorbid organ failure predicts poor outcome.
- Recurrence: 4-24% even after cholecystectomy; related to residual increased intrabiliary pressure, biliary tract ectasias, focal strictures, intrahepatic pigment stones, and parasitic infections
COMPLICATIONS
- Acute pancreatitis
- Hepatic abscess, dysfunction, and atrophy
- Bacteremia and sepsis
- Inadequate biliary drainage
- Bile peritonitis, portal vein thrombosis, gallstone ileus
- Acute renal failure
- ~1-3% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) develop cholangitis.
REFERENCES
11 Weber A, Schneider J, Wagenpfeil S, et al. Spectrum of pathogens in acute cholangitis in patients with and without biliary endoprosthesis. J Infect. 2013;67(2):111-121.22 Gossard AA, Talwalkar JA. Cholestatic liver disease. Med Clin North Am. 2014;98(1):73-85.33 Bencini L, Tommasi C, Manetti R, et al. Modern approach to cholecysto-choledocholithiasis. World J Gastrointest Endosc. 2014;6(2):32-40.44 Dasari BV, Tan CJ, Gurusamy KS, et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2013;(12):CD003327.55 Miura F, Takada T, Strasberg SM, et al. TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013;20(1):47-54.66 Park TY, Choi JS, Song TJ, et al. Early oral antibiotic switch compared with conventional intravenous antibiotic therapy for acute cholangitis with bacteremia. Dig Dis Sci. 2014;59(11):2790-2796.
SEE ALSO
Cholelithiasis
CODES
ICD10
K83.0 Cholangitis
ICD9
576.1 Cholangitis
SNOMED
Acute cholangitis
CLINICAL PEARLS
- Charcot triad (fever, jaundice, and RUQ pain) is seen in <25% of cases and has low sensitivity but high specificity for diagnosing ascending cholangitis.
- With a partial biliary obstruction, an isolated elevation of alkaline phosphatase is often seen in this setting
- Cholangitis requires rapid recognition and intervention to relieve biliary obstruction. A high index of clinical suspicion is required for the diagnosis, particularly in elderly patients.
- Malignant obstruction (Courvoisier sign) rarely presents with cholangitis because biliary obstruction is slow and progressive, allowing for compensatory gallbladder expansion.