Ascending Cholangitis

Ascending cholangitis, also known as acute cholangitis or simply cholangitis, is an inflammation of the bile duct primarily caused by bacterial infection ascending from the duodenum.

This condition is often associated with partial obstruction of the bile duct by gallstones and can be life-threatening, thus necessitating prompt medical intervention.

Duodenoscopy image of pus extruding from the ampulla of Vater, indicative of cholangitis

Signs and Symptoms

Patients with cholangitis typically present with jaundice, fever, and right upper quadrant abdominal pain, collectively known as Charcot's triad. However, this classic triad is present in only 15–20% of cases. Additionally, some patients may exhibit Reynolds' pentad, which includes the elements of Charcot's triad plus septic shock and mental confusion, indicating severe infection and possible sepsis. Elderly patients may exhibit atypical presentations, such as collapsing directly due to sepsis without prior symptoms.

Charcot's triad: abdominal pain, jaundice, and fever

Causes

The primary cause of cholangitis is bile duct obstruction, often due to gallstones. Other causes include benign strictures, postoperative damage, parasitic infections, or tumours such as pancreatic or gallbladder cancer. Opportunistic infections in AIDS patients and complications from procedures like ERCP can also result in cholangitis. Permanent biliary stents, often used in cases like pancreatic cancer, slightly increase the risk of infection.

Pathogenesis

Bile, produced by the liver, aids in digestion and the elimination of waste products. Normally, the biliary system is nearly sterile due to mechanical barriers like the sphincter of Oddi, continuous bile flow, and the protective constitution of bile. However, obstruction increases biliary pressure, allowing bacteria, typically gram-negative bacilli, to enter the bloodstream, leading to systemic inflammatory response syndrome (SIRS) and sepsis.

Diagram showing liver and related parts of the digestive system

Diagnosis

Blood Tests

Blood tests typically reveal raised white blood cell counts, elevated C-reactive protein levels, and abnormal liver function tests. Blood cultures may identify the causative bacteria, with Escherichia coli, Klebsiella, and Enterobacter being the most common pathogens.

Medical Imaging

Ultrasound is usually the initial imaging modality to detect bile duct dilation and stones. Magnetic resonance cholangiopancreatography (MRCP) offers superior sensitivity for detecting bile duct obstructions. Endoscopic retrograde cholangiopancreatography (ERCP), the gold standard, is used to visualise and treat obstructions when immediate intervention is necessary.

Cholangiogram through a nasobiliary drain showing the common bile duct in black with an interruption due to a large gallstone

Treatment

Fluids and Antibiotics

Hospital admission is required. Initial treatment involves administering intravenous fluids and broad-spectrum antibiotics, such as penicillins combined with aminoglycosides or ciprofloxacin, sometimes with metronidazole for anaerobic bacteria. Antibiotics are typically continued for 7–10 days.

Endoscopy

Definitive treatment focuses on relieving the biliary obstruction via ERCP. This involves endoscopic sphincterotomy, stone extraction, or dilation of the common bile duct. Large stones may require additional techniques like mechanical lithotripsy or extracorporeal shock wave lithotripsy. Stents may be placed to keep the duct open, and a nasobiliary drain might be used for continuous drainage.

Percutaneous Biliary Drainage

For patients too ill for endoscopy or when ERCP fails, percutaneous transhepatic cholangiogram (PTC) with percutaneous biliary drainage (PBD) may be performed to relieve the obstruction.

Cholecystectomy

Surgical removal of the gallbladder is generally recommended to prevent recurrence of gallstone-related cholangitis. This is typically delayed until the infection and obstruction are resolved.

Prognosis

The mortality rate of acute cholangitis has significantly decreased with advances in diagnosis and treatment, now ranging between 10–30%. Early biliary drainage and systemic antibiotics are very important for survival, particularly in cases of multiple organ failure. Risk factors for increased mortality include older age, female gender, liver cirrhosis, and biliary tract cancers. Complications can include kidney and respiratory failure, abnormal heart rhythms, and gastrointestinal bleeding.

Self-assessment MCQs (single best answer)

What is the primary cause of ascending cholangitis?

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Which of the following is NOT a component of Charcot's triad?

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What imaging modality is considered the gold standard for visualising and treating bile duct obstructions in cholangitis?

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Which of the following organisms is most commonly associated with ascending cholangitis?

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Reynolds' pentad includes all elements of Charcot's triad plus which two additional symptoms?

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What initial treatment is typically administered to a patient with ascending cholangitis upon hospital admission?

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What is the purpose of performing an endoscopic sphincterotomy during ERCP in cholangitis treatment?

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Which procedure might be necessary for patients too ill for endoscopy or when ERCP fails?

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What is a common long-term treatment to prevent recurrence of gallstone-related cholangitis?

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Which of the following factors is NOT associated with increased mortality in acute cholangitis?

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