Acute Cholangitis

Cholangitis is inflammation and infection of the bile ducts, which are the tubes that carry bile from the liver and gallbladder to the small intestine. A blockage in these ducts causes bile to back up, leading to a bacterial infection and a life-threatening condition that requires immediate medical attention. 

Common causes

  • Blockage in the bile duct: This is the most common cause of acute cholangitis. The blockage can be due to a gallstone, a tumor, blood clots, or scarring from a previous surgery.

  • Autoimmune conditions: Certain autoimmune disorders, like primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), cause chronic inflammation and scarring in the bile ducts.

  • Medical procedures: Rarely, a medical procedure involving the bile ducts, such as an ERCP (endoscopic retrograde cholangiopancreatography), can cause an infection.

  • Parasitic infections: In some parts of the world, parasitic worms or liver flukes can cause a blockage in the bile ducts.

  • Other conditions: HIV, certain tumors, and other infections can also lead to cholangitis. 

Signs and symptoms

The symptoms of cholangitis can be severe and may come on suddenly. Doctors often recognize the combination of fever, right upper abdominal pain, and jaundice, known as Charcot's triad. 

  • Fever and chills: High fever is a common sign of the infection.

  • Right upper abdominal pain: The pain is usually located in the upper right part of the belly, where the liver and bile ducts are situated.

  • Jaundice: A yellowing of the skin and whites of the eyes caused by bile backing up into the bloodstream.

  • Nausea and vomiting: Digestive symptoms frequently accompany the pain.

  • Dark urine and clay-colored stools: This occurs because the bile pigment (bilirubin) is not properly eliminated from the body.

  • Fatigue: Feeling extremely tired or lethargic is common.

  • Confusion and low blood pressure: In severe cases (Reynolds' pentad), the infection can lead to septic shock, causing confusion and a drop in blood pressure. 

Diagnosis

Because cholangitis can be a medical emergency, rapid and accurate diagnosis is crucial.

  1. Medical history and physical exam: The doctor will check for the classic symptoms and ask about your health history, particularly any history of gallstones or liver disease.

  2. Blood tests: A blood test can reveal a high white blood cell count (a sign of infection) and elevated liver enzyme levels, indicating a bile duct blockage.

  3. Imaging tests:

    1. Ultrasound: Often the first test, it can show bile duct dilation (swelling) and the presence of gallstones.

    2. CT scan or MRI: These tests can provide more detailed images of the bile ducts and surrounding organs.

    3. MRCP (Magnetic Resonance Cholangiopancreatography): A specialized MRI that creates detailed pictures of the bile ducts.

  4. ERCP (Endoscopic Retrograde Cholangiopancreatography): This procedure uses an endoscope to access and visualize the bile ducts. It is often used for both diagnosis and treatment. 

Treatment

Treatment for acute cholangitis typically requires hospitalization and a two-pronged approach: clearing the infection and relieving the blockage. 

  • Antibiotics: Broad-spectrum antibiotics are given intravenously to treat the bacterial infection. Treatment often lasts for 7 to 10 days.

  • Biliary drainage: To relieve the blockage and allow bile to drain, a doctor may perform one of the following procedures:

    • ERCP: The most common method, an ERCP is used to remove gallstones or place a stent (a small tube) to keep the duct open.

    • PTBD (Percutaneous Transhepatic Biliary Drainage): If an ERCP isn't possible, a needle can be inserted through the skin and liver to place a drain in the bile duct.

    • Surgery: In some complex cases, surgery may be necessary to remove the obstruction.

  • Treatment for chronic cholangitis: For autoimmune types like PSC, treatments focus on managing inflammation and symptoms. This can include medications, vitamin supplements, and, eventually, a liver transplant if the liver fails.

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