Acute Cholangitis

Acute cholangitis is infection and inflammation in the bile ducts. It is a surgical emergency and has a high mortality due to sepsis and septicaemia.

There are two main causes of acute cholangitis:

  • Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct)
  • Infection introduced during an ERCP procedure

 

The most common organisms are:

  1. Escherichia coli 
  2. Klebsiella species
  3. Enterococcus species

 

Charcot’s Triad

Acute cholangitis presents with Charcot’s triad:

  • Right upper quadrant pain
  • Fever
  • Jaundice (raised bilirubin)

 

TOM TIP: It is worth remembering Charcot’s triad. If you see a patient in your exams with fever, raised bilirubin and right upper quadrant pain, you know the diagnosis is acute cholangitis. 

 

Management

Patients with suspected acute cholangitis need emergency admission for investigations and management.

Patients need acute management of sepsis and acute abdomen, including:

  • Nil by mouth
  • IV fluids
  • Blood cultures
  • IV antibiotics (as per local guidelines)
  • Involvement of seniors and potentially HDU or ICU

 

Imaging to diagnose common bile duct (CBD) stones and cholangitis (from least to most sensitive) are:

  • Abdominal ultrasound scan
  • CT scan
  • Magnetic resonance cholangio-pancreatography (MRCP)
  • Endoscopic ultrasound 

 

An endoscopic retrograde cholangio-pancreatography (ERCP) is required to remove stones blocking the bile duct. It involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the sphincter of Oddi). This gives the operator access to the biliary system. A number of procedures can be performed during an ERCP:

  • Cholangio-pancreatography: retrograde injection of contrast into the duct through the sphincter of Oddi and x-ray images to visualise biliary system
  • Sphincterotomy: making a cut in the sphincter to dilate it and allow stone removal
  • Stone removal: a basket can be inserted and pulled through the common bile duct to remove stones
  • Balloon dilatation: a balloon can be inserted and inflated to treat strictures
  • Biliary stenting: a stent can be inserted to maintain a patent bile duct (for strictures or tumours)
  • Biopsy: a small biopsy can be taken to diagnose obstructing lesions

 

Percutaneous transhepatic cholangiogram (PTC) involves radiologically guided insertion of a drain through the skin and liver, into the bile ducts. The drain relieves the immediate obstruction. A stent can be inserted to give longer-lasting relief of obstruction. This is an option for patients that are less suitable for ERCP, or where ERCP has failed. 

 

Last updated May 2021
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