Cholangitis is an infection of the biliary tree that requires prompt diagnosis and treatment.
Ascending cholangitis is the historical term for the condition currently referred to as acute cholangitis.
Most patients have fever, jaundice, and right upper quadrant pain (Charcot triad).
Cholangitis can quickly become an acute, septic, life-threatening infection that requires rapid evaluation and treatment.
The most common causes are choledocholithiasis and benign and malignant strictures.
Antibiotics alone do not provide sufficient treatment in the majority of patients. Drainage of the biliary tree is the most critical step in management.
If untreated, sepsis with shock, vascular collapse, multiorgan failure, and potentially death can occur.
Ascending cholangitis is the historical term for the condition currently referred to as acute cholangitis or simply as cholangitis.
Acute cholangitis is an infection of the biliary tree, most commonly caused by obstruction. In its less severe form, there is biliary obstruction with inflammation and bacterial seeding and growth in the biliary tree. It is estimated that 50% to 70% of these patients present with right upper quadrant pain, fever, and jaundice. In the more severe, life-threatening form, known as toxic cholangitis or cholangitis with sepsis, patients have purulent biliary tree contents, as well as evidence of sepsis, hypotension, multiorgan failure, and mental status changes.
History and exam
Key diagnostic factors
- right upper quadrant (RUQ)/upper abdominal pain
- RUQ/upper abdominal tenderness
Other diagnostic factors
- pale stools
- mental status changes
- age >50 years
- benign stricture
- malignant stricture
- postprocedure injury of bile ducts
- history of primary sclerosing cholangitis
- history of secondary sclerosing cholangitis
- HIV infection
1st investigations to order
- serum BUN
- serum creatinine
- ABG analysis
- serum LFTs
- serum potassium
- serum magnesium
- blood cultures
- coagulation panel
- transabdominal ultrasound
- endoscopic retrograde cholangiopancreatography (ERCP)
Investigations to consider
- abdominal CT scan with intravenous contrast
- magnetic resonance cholangiopancreatography (MRCP)
- endoscopic ultrasonography (EUS)
- percutaneous trans-hepatic cholangiography (PTC)
- surgical approaches
with choledocholithiasis, PSC, or HIV cholangiopathy
- Acute cholecystitis
- Peptic ulcer disease
- Acute pancreatitis
- TG18 management bundles for acute cholangitis and cholecystitis
- TG18 initial management of acute biliary infection and flowchart for acute cholangitis
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