CHOLANGITIS
General
- Cholangitis refers to an acute infection of the biliary tree, and has the potential to
cause significant morbidity and mortality. It occurs secondary to stasis or
obstruction of bile compounded by the presence of bacteria. Choledocholithiasis
(stones in the common bile duct) has long been the most common cause of
obstruction, however, strictures, tumors, or manipulation of the common bile duct
may cause bile stasis, leading to the predisposition to bacterial infection of the
biliary tree. The most common organisms associated with Cholangitis are those
found in the gut (E Coli, Klebsiella, Enterobacter, Enterococci, and Group D
Streptococci).
- Charcot recognized cholangitis in 1877 when he described what has come to be
known as Charcot's Triad (Fever, Jaundice, RUQ pain). Reynolds and Dargon, in
1959, described a more severe form of the illness which included Charcot's Triad
plus the addition of hypotension (septic shock) and mental status changes, thus
coining the term Reynold's Pentad.
+ Charcot's Triad : Fever, Jaundice, RUQ Pain
+ Reynold's Pentad : Fever, Jaundice, RUQ Pain, Hypotension, Mental Status
Changes
- Cholangitis occurs relatively infrequently in the US, and as it most commonly
associated with gallstones, the risk factors for development are essentially the
same. Importantly, however, although the risk of gallstones is higher in women,
than in men, cholangitis occurs equally in both sexes. Untreated, the mortality of
cholangitis is high (13-88%). Characteristics associated with increased mortality
include hypotension, acute renal failure, liver abscess, cirrhosis, and IBD.
Clinical Presentation
- Scleral icterus of jaundice
- A spectrum of cholangitis exists, from mild illness to fulminant, overwhelming
sepsis. Charcot's Triad of fever, jaundice, and RUQ pain classically occur in up to
70% of patients presenting with illness, however, some patients (particularly the
elderly) are too ill to localize the infection. A past medical history of gallstones,
recent cholecystectomy, ERCP, or history of cholangitis are helpful in elucidating
the diagnosis. Scleral icterus, fever, pruritis, and mild hepatomegaly all help
support the diagnosis. The findings of mental status changes and hypotension
indicate pregression of the disease to ascending cholangitis and warrants
immediate care.
Treatment
- Essential medical care for cholangitis includes the administration of broad
spectrum antibiotics and correction of fluid and electrolyte abnormalities. Because
of the high biliary pressures created by obstruction, the biliary secretion of
antibiotics can become impaired. In these instances, decompression and drainage
of the biliary system becomes tantamount.
- Endoscopic biliary drainage and decompression and transhepatic drainage have
pretty much replaced surgery as the initial treatment for severe or overwhelming
cholangitis. Surgical decompression is appropriate in patients for which
endoscopic or transhepatic drainage is unsuccessful or unavailable.