Basics
Description
- Partial or complete obstruction of the common bile duct owing to gallstones, tumor, cyst, or stricture
- Increased intraluminal pressure in biliary tree
- Bacterial multiplication results in bacteremia and sepsis.
- Purulent infection of biliary tree, which may involve the liver and gallbladder
- Mirizzi syndrome is defined as common bile duct obstruction owing to extrinsic compression from gallbladder or cystic duct edema or stones.
Etiology
- Bacterial sources of infection include:
- Ascending duodenal source
- Gallbladder infection
- Portal venous seeding
- Hematogenous spread with hepatic secretion
- Lymphatic spread
- Bacterial organisms include:
- Anaerobes (Bacteroides and Clostridium species)
- Intestinal coliform (Escherichia coli)
- Enterococcus
- AIDS sclerosing cholangitis characterized by:
- Papillary stenosis
- Sclerosing cholangitis
- Extrahepatic biliary obstruction
- Cytomegalovirus (CMV), Cryptosporidium, and microsporidia isolated, but causal role not established
Diagnosis
Signs and Symptoms
History
- Charcot triad:
- Classic presentation of fever and chills; right upper quadrant (RUQ) pain and jaundice found in only 50-70%
- Addition of shock and altered mental status denotes a more advanced form of biliary sepsis known as Reynolds pentad.
- Abdominal pain present in >70%-localizing to RUQ.
- AIDS sclerosing cholangitis presents with similar symptoms but with more chronic indolent course and near-normal serum bilirubin levels.
Physical Exam
- Fever found in >90%
- Peritoneal findings found in 30%
- Clinically apparent jaundice may be absent in up to 40%.
Essential Workup
- ECG in patients at risk for coronary artery disease
- CBC
- LFT
- Amylase, lipase
- Urinalysis
- Blood cultures
- Gallbladder US or hepatoiminodiacetic acid (HIDA) scan
Diagnosis Tests & Interpretation
Lab
- CBC:
- Leukocytosis with left shift unless immunocompromised or severe sepsis
- LFTs consistent with cholestasis:
- Elevated direct bilirubin and alkaline phosphatase
- Minimal elevation of transaminases (<200 IU/mL)
- Changes may lag symptom onset by 24-48 hr.
- Amylase and lipase normal or mildly elevated
- Urinalysis positive for bilirubin
Imaging
- US detects the level of ductal obstruction and the presence of gallstone etiology.
- Radionuclide scanning (HIDA):
- Indicates obstruction when tracer not found in duodenum within 1 hr
- More sensitive than US in detecting obstruction in the 1st 24-48 hr before ductal dilation occurs
- CT scan and CRX:
- Useful to rule out intestinal obstruction, perforation, or pneumonia
- 20% gallstones radiopaque
- Magnetic resonance cholangiopancreatography (MRCP) is highly accurate for biliary obstruction but unnecessary if endoscopic retrograde cholangiopancreatography (ERCP) will be performed.
Diagnostic Procedures/Surgery
Emergency invasive biliary imaging and drainage by ERCP (or surgical/percutaneous if not available), if no response to medical treatment in 12-24 hr
Differential Diagnosis
- Acute cholecystitis
- Hepatitis or hepatic abscess
- Acute pancreatitis
- Right pyelonephritis
- Right lower lobe pneumonia or pulmonary embolism
- Perforated duodenal ulcer
- Appendicitis
- Sepsis with nonspecific elevation of LFTs
- Fitz-Hugh and Curtis syndrome
Treatment
Pre-Hospital
Stabilize septic shock.
Initial Stabilization/Therapy
- Immediate IV fluid resuscitation for dehydration, hemodynamic compromise, and sepsis
- 80% respond to IV antibiotics within 1st 24 hr
- Vasopressors (dopamine) for hypotension refractory to volume replacement
Ed Treatment/Procedures
- Broad-spectrum antibiotics for coliforms, anaerobes, and enterococcus such as:
- Ampicillin/sulbactam + aminoglycoside (e.g., gentamicin)
- Imipenem-cilastatin
- Piperacillin/tazobactam + aminoglycoside (e.g., gentamicin)
- For penicillin allergy:
- Adults-use levofloxacin (Levaquin) and metronidazole
- Pediatrics-use clindamycin and metronidazole
- Substitute aztreonam for aminoglycoside in renal insufficiency.
- NPO
- Nasogastric (NG) suctioning if protracted vomiting or ileus
- IV fluid (0.9% NS) replacement and maintenance
- Narcotic analgesia if hemodynamically stable and diagnosis reasonably established
- Immediate surgical and GI consultation
- Emergency invasive biliary drainage procedure (surgical, percutaneous, or ERCP) if no response to medical treatment in 12-24 hr
Medication
- Ampicillin/sulbactam: 3 g (peds: 200 mg/kg/24 h) IV piggyback (IVPB) q6h
- Aztreonam: 2 g (peds: 120 mg/kg/24 h) IVPB q6h
- Clindamycin: 600-900 mg (peds: 25-40 mg/kg/24 h) IVPB q6-8h
- Dopamine: 2-20 μg/min IVPB; titrate to maintain BP
- Gentamicin: 1.5-2 mg/kg (peds: 6-7 mg/kg/24 h) IVPB q8h; follow levels
- Imipenem-cilastatin: 500 mg (Peds 60-100 mg/kg/24 h) q6h
- Levaquin: 500 mg IVPB q24h; contraindicated in peds
- Hydromorphone: 0.5-2 mg IV (0.01-0.02 mg/kg), titrated to pain relief.
- Metronidazole: 500 mg (peds: 30 mg/kg/24 h) IVPB q6h
- Piperacillin/tazobactam: 3.375 mg (peds: 300 mg/kg/24 h) IVPB q6h
- Ondansetron: 4-8 mg IV, (0.15-0.3 mg/kg) IV (not to exceed 8 mg/dose IV), q4h PRN vomiting
Follow-Up
Disposition
Admission Criteria
- All patients with acute cholangitis should be admitted with immediate surgical and gastroenterologic consultation.
- Admit patients with signs of septic shock to the ICU.
Discharge Criteria
None
Issues for Referral
Surgery/GI consultation
Followup Recommendations
Admission to hospital for IV antibiotic and possible biliary drainage procedure.
Pearls and Pitfalls
- Aggressively fluid resuscitate patients.
- Administer antibiotics.
- Obtain GI and surgical consultations.
Additional Reading
- Jackson PG, Evans SR. Biliary system. In: Townsend CM Jr, ed. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: WB Saunders; 2012:1476-1514.
- Kinney TP. Management of ascending cholangitis. Gastrointest Endosc Clin N Am. 2007;17:289-306.
- Silen W. Cholecystitis and other causes of acute pain in the right upper quadrant of the abdomen. In: Silen W, ed. Copes Early Diagnosis of the Acute Abdomen. 22nd ed. Oxford, UK: Oxford University Press; 2010:131-141.
- Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis. 2010;50:997; 133-164.
- Yusuf TE, Baron TH, AIDS Cholangiopathy. Curr Treat Options Gastroenterol. 2004;7:111-117.
See Also (Topic, Algorithm, Electronic Media Element)
- Cholecystitis
- Cholelithiasis
Codes
ICD9
576.1 Cholangitis
ICD10
K83.0 Cholangitis
SNOMED
- 82403002 Cholangitis (disorder)
- 235917005 Sclerosing cholangitis (disorder)
- 281388009 Human immunodeficiency virus HIV-related sclerosing cholangitis (disorder)
- 26918003 Ascending cholangitis (disorder)
- 6215006 Acute cholangitis