Cholangitis

“Infection due to obstruction of the biliary tree”

Risk Factors

• Gallstones
• Recent biliary tract procedure or previous cholangitis.
• Medication e.g. COCP, fibrates.
• Lipid-rich diet – increased incidence of gallstones

Aetiology

• Any condition causing occlusion of biliary tree.
  • Biliary calculi (80%)
  • Benign biliary stricture
  • Malignancy (cholangiocarcinoma).
• Following biliary procedures e.g. ERCP
  • Particularly following post-op stent placement or bile duct injury (iatrogenic).
• Obstruction of the bile duct can also result from external compression e.g. Lemmel syndrome, Mirizzi syndrome or inflammation secondary to acute pancreatitis.
• Intrinsic obstruction can be caused by blood clots or parasites.
• Sclerosing cholangitis (inflammation and scarring of bile ducts causing narrowing).

Pathophysiology

• Biliary tree obstruction → bile stasis + elevated intraluminal pressure → bacterial colonisation of the duct (most commonly E. coli, Klebsiella or Enterococcus

Clinical Presentation

• Charcot’s triad- Fever, Jaundice and RUQ pain
• Reynold’s pentad – Charcot’s triad + hypotension and mental status changes

Investigations

• Bloods:
  • FBC (leucocytosis)
  • LFTS (raised ALP +/- GGT and raised bilirubin)
  • Blood cultures
• Imaging:
  • USS of biliary tract → bile duct dilation (>7mm)
• Special:
  • Gold Standard – ERCP (Diagnosis & therapeutic)
  • May require MRCP to obtain detailed image prior to intervention

Management

• Immediate:
  • ?sepsis → IV access → fluid resuscitation, routine bloods and blood cultures, broad spec antibiotics e.g. co-amoxiclav + metronidazole
  • Endoscopic biliary decompression (remove cause of obstruction) → via ERCP (+/- spincterotomy/stenting) or percutaneous transhepatic cholangiography if patient too sick
• Long term:
  • Cholecystectomy if gallstones were cause, management of other underlying causes

Complications

• ERCP complications:
  • Repeated cholangitis
  • Pancreatitis
  • Bleeding
  • Perforation