24th July 2023

Acute cholangitis

Also known as ascending cholangitis, this refers to infection of the biliary tree. If untreated, it can lead to biliary sepsis, which carries a significant mortality risk. Cholangitis is, therefore, a medical emergency.

Causes and risk factors

Cholangitis occurs in the context of biliary obstruction; hence, the vast majority of cases are due to gallstones. Other causes of obstruction (and therefore cholangitis) include biliary strictures, pancreatic cancer, primary sclerosing cholangitis, and amyloidosis.

Therefore, for the majority, the risk factors are the same as for gallstones.

Clinical features

Cholangitis is characterised by Charcot’s triad of abdominal pain, jaundice and fever. The pain is constant, severe, and generally localises to the right upper quadrant. Patients may become hypotensive, and there is a risk of sepsis. Confusion may also develop as the disease progresses.

The presence of jaundice is a key distinguishing feature from biliary colic and cholecystitis, in which it is more rare.

Assessment and diagnosis

Blood tests will show raised inflammatory markers and elevated cholestatic LFTs. Ultrasound scan is generally the first line imaging investigation, but ERCP is the gold standard diagnostic test. MRCP and endoscopic-guided ultrasound (EUS) are also highly sensitive.

Management

An ABCDE approach should be taken, with the first focus on resuscitation with IV fluids, and then pain control. IV antibiotics (generally cefuroxime and metronidazole) are the first line treatment for the infection.

Therapeutic drainage of the bile duct should be done once the patient is stabilised, with ERCP (which can also be used to confirm diagnosis). Surgical drainage should only be done if ERCP is contraindicated or unsuccessful (i.e. the patient is too unstable, existing bowel perforation).