eMedicine Specialties > Gastroenterology > Biliary

Cholangitis

Author: Homayoun Shojamanesh, MD, Former Fellow, Digestive Diseases Branch, National Institutes of Health
Coauthor(s): Praveen K Roy, MD, Comments and Criticisms Editor, Cochrane Colorectal Cancer Group; Victor Nwakakwa, MD, MRCP (UK), Clinical Instructor, Department of Internal Medicine, Division of Gastroenterology, University of Virginia Health System
Contributor Information and Disclosures

Updated: Jun 4, 2006

Introduction

Background

Cholangitis is an infection of the biliary tract with the potential to cause significant morbidity and mortality. Many patients with acute cholangitis respond to antibiotic therapy; however, patients with severe or toxic cholangitis may not respond and may require emergency biliary drainage. Jean M. Charcot recognized this illness in 1877 when he described a triad of fever, jaundice, and right upper quadrant pain. In 1959, Reynolds and Dargon described a more severe form of the illness that included the additional components of septic shock and mental confusion, which is referred to as the Reynolds pentad.

Pathophysiology

Historically, choledocholithiasis was the most common cause of biliary tract obstruction resulting in cholangitis. Over the past 20 years, biliary tract manipulations/interventions and stents have reportedly become more common causes of cholangitis. Hepatobiliary malignancies are a less common cause of biliary tract obstruction and subsequent bile contamination.

Mortality/Morbidity

The condition has significant potential for mortality and morbidity, especially if left untreated. Reported mortality rates vary from 13-88%.

Race

Cholangitis is reported in all races. One variant, Asian cholangitis (also referred to as recurrent pyogenic cholangitis), is observed with increased frequency in Southeast Asia.

Sex

The condition is reported in both females and males and has no clear predominance in either.

Age

The condition mostly occurs in adults, with a reported median age at onset of 50-60 years.

Clinical

History

A history of choledocholithiasis or recent biliary tract manipulation associated with fever, abdominal (right upper quadrant) pain, and jaundice (the Charcot triad) is highly suggestive of cholangitis. Fever reportedly occurs in nearly 95% of patients with cholangitis. Approximately 90% of patients have right upper quadrant tenderness, and 80% have jaundice.

Physical

Physical examination may reveal fever, icterus, jaundice, and abdominal pain.

Causes

Two main causes of cholangitis are biliary tract manipulation and common bile duct stones. Other possible causes of biliary tract obstruction that may lead to infection include strictures, tumors, choledochal/biliary cysts, or sump syndrome. Hepatolithiasis is also a possible cause of cholangitis and is observed more frequently in East Asia. More than 90% of patients with hepatolithiasis have calcium bilirubinate stones, also referred to as brown pigment stones.

More on Cholangitis

Overview: Cholangitis
Differential Diagnoses & Workup: Cholangitis
Treatment & Medication: Cholangitis
Follow-up: Cholangitis
References
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References

  1. Bilhartz LE, Horton JD. Gallstone disease and its complications. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. 1998:948-972.

  2. Hanau LH, Steigbigel NH. Acute (ascending) cholangitis. Infect Dis Clin North Am. Sep 2000;14(3):521-46. [Medline].

  3. Kadakia SC. Biliary tract emergencies. Acute cholecystitis, acute cholangitis, and acute pancreatitis. Med Clin North Am. Sep 1993;77(5):1015-36. [Medline].

  4. Lai EC, Mok FP, Tan ES, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med. Jun 11 1992;326(24):1582-6. [Medline].

  5. Lameris JS, Overhagen HV. Imaging and intervention in patients with acute right upper quadrant disease. In: Bailliere's Clinical Gastroenterology. Vol 9. Harcourt Brace & Co;1995:21-36.

  6. Lee DW, Chung SC. Biliary infection. In: Bailliere's Clinical Gastroenterology. Vol 11. Harcourt Brace & Co;1997:707-724.

  7. Leung JW, Yu AS. Hepatolithiasis and biliary parasites. Bailliere's Clinical Gastroenterology. 1997;11:681-706.

  8. Lillemoe KD. Surgical treatment of biliary tract infections. Am Surg. Feb 2000;66(2):138-44. [Medline].

  9. Lipsett PA, Pitt HA. Acute cholangitis. Surg Clin North Am. Dec 1990;70(6):1297-312. [Medline].

  10. Raraty MG, Finch M, Neoptolemos JP. Acute cholangitis and pancreatitis secondary to common duct stones: management update. World J Surg. Nov 1998;22(11):1155-61. [Medline].

  11. van den Hazel SJ, Speelman P, Tytgat GN, et al. Role of antibiotics in the treatment and prevention of acute and recurrent cholangitis. Clin Infect Dis. Aug 1994;19(2):279-86. [Medline].

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Further Reading

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Keywords

choledocholithiasis, biliary tract obstruction, angiocholitis, cholangeitis, hepatolithiasis, sump syndrome, pyogenic liver abscess, acute renal failure, Escherichia coli, E coli, Klebsiella species, Enterococcus species, Bacteroides fragilis, B fragilis

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Contributor Information and Disclosures

Author

Homayoun Shojamanesh, MD, Former Fellow, Digestive Diseases Branch, National Institutes of Health
Homayoun Shojamanesh, MD is a member of the following medical societies: American Gastroenterological Association, American Medical Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Coauthor(s)

Praveen K Roy, MD, Comments and Criticisms Editor, Cochrane Colorectal Cancer Group
Praveen K Roy, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and Canadian Association of Gastroenterology
Disclosure: Nothing to disclose.

Victor Nwakakwa, MD, MRCP (UK), Clinical Instructor, Department of Internal Medicine, Division of Gastroenterology, University of Virginia Health System
Disclosure: Nothing to disclose.

Medical Editor

Anil Minocha, MD, FACP, FACG, Clinical Professor, School of Pharmacy, Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center
Anil Minocha, MD, FACP, FACG is a member of the following medical societies: American Academy of Clinical Toxicology, American Association for the Study of Liver Diseases, American College of Forensic Examiners, American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

James L Achord, MD, Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine
James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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