Acute Cholangitis

 Acute Cholangitis 

1. Definition

Acute cholangitis is a life-threatening ascending infection of the biliary tree occurring due to biliary obstruction + bacterial infection.

Classic triad = Charcot’s triad

• Fever
• Jaundice
• Right upper quadrant pain

Severe disease = Reynolds pentad

• Charcot triad
• Hypotension
• Altered mental status

Charcot triad present in ~50–70% only → absence does NOT exclude cholangitis.

2. Pathophysiology

Mechanism

1. Obstruction of bile duct
• Stone (most common)
• Tumour
• Stricture
• Stent blockage

2. → ↑ Intraductal pressure (>20 cm H₂O)
3. → Breakdown of tight junctions
4. → Bacteriobilia → Bacteraemia(Most infections are ascending infections from the duodenum.)
5. → Sepsis / Septic shock

3. Causes of Biliary Obstruction

4. Microbiology 

Most common organisms

• E. coli (most common)
• Klebsiella
• Enterobacter
• Enterococcus fecalis/facium(Gram-Positive Organisms)
• Bacteroides(Anaerobes are less commonMore frequent in: Prior biliary surgery,Bilioenteric anastomosis)

 Infection is usually polymicrobial.

5. Clinical Features

 Early disease

• Fever with rigors(Infection)
• RUQ pain(Obstruction)
• Jaundice(Cholestasis)
• Nausea/vomiting

 Severe disease

• Hypotension(Sepsis)
• Confusion(Organ dysfunction)
• Oliguria
• Septic shock

6. Tokyo Guidelines 

Diagnosis requires:Diagnosis = A + B + C

A. Systemic Inflammation

At least one:

Clinical

• Fever >38°C
• Chills/rigors

Laboratory

• WBC <4,000 or >10,000/mm³
• CRP elevated

B. Cholestasis

At least one:

Jaundice-Bilirubin ≥2 mg/dL

Abnormal LFTs-1.5 × upper limit of normal

ALP elevated/GGT elevated
AST elevated/ALT elevated

C. Imaging Evidence

One of:

• Biliary dilatation
• Stone
• Stricture
• Stent obstruction
• Other obstructive lesion

7. Severity Grading (Tokyo Guidelines)

• Grade I (Mild)
• Grade II (Moderate)

Any 2:

• WBC >12,000 or <4,000
• Fever >39°C
• Age >75
• Hyperbilirubinaemia
• Low albumin

→ Early drainage (within 24–48 hrs)

 Grade III (Severe)

Organ dysfunction:

• Hypotension requiring vasopressors
• Altered mental state
• PaO₂/FiO₂ <300
• Creatinine >176 μmol/L
• INR >1.5
• Platelets <100

→ Requires urgent biliary drainage within 24 hours

8. Investigations

Bloods

• FBC → neutrophilia
• CRP ↑
• Bilirubin ↑
• ALP ↑
• GGT ↑
• ALT mild ↑
• Blood cultures (before antibiotics)

Imaging

Ultrasound (First-line)

Findings:

• Dilated CBD (>6 mm)
• Stone
• Gallbladder pathology

MRCP (Best non-invasive test)

• Defines level of obstruction
• No therapeutic role

ERCP (Gold standard – Diagnostic + Therapeutic)

• Stone extraction
• Stenting
• Drainage

9. Management 

Antibiotic Therapy + Urgent Biliary Drainage

Antibiotic Therapy Principles

Start immediately after cultures.

Coverage should include:

• Gram-negative enteric organisms
• Enterococcus (selected patients)
• Anaerobes when indicated

Duration is generally:

After Successful Source Control

4–7 days

Empiric Antibiotics

Mild Community-Acquired Disease

Moderate Disease

Severe Disease / Septic Shock

Risk of ESBL

Preferred:

Enterococcus Coverage

Consider if:

• Prior biliary instrumentation
• Transplant
• Healthcare-associated infection

Options:

• Ampicillin
• Vancomycin

Urgent Biliary Drainage

Preferred: ERCP

If ERCP fails:

• PTBD (percutaneous transhepatic drainage)
• Surgery (rare)

10. Complications

• Septic shock
• Liver abscess
• Acute kidney injury
• DIC
• Death (mortality up to 10–20%)

11. Differentials