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Recurrent Pyogenic Cholangitis Clinical Presentation

  • Author: Praveen K Roy, MD, AGAF; Chief Editor: Julian Katz, MD  more...
 
Updated: Jul 24, 2015
 

History

Patients may present with the following: (1) an acute attack of cholangitis, (2) a history of recurrent attacks of cholangitis typified by fevers and right upper quadrant (RUQ) abdominal pain, or (3) complications of pyogenic cholangitis. As the disease progresses, patients may develop cholangiocarcinoma and present with constitutional symptoms, including weight loss, easy fatigability, and jaundice.[2, 3]

Roughly one third of patients present with an initial episode of RPC. The typical presentation is a patient older than 30 years who is from an endemic region and reports with complaints of fevers, RUQ abdominal pain, and jaundice (Charcot triad). Atypical presentations without all of the components of the triad are somewhat infrequent but may confound the diagnosis, and a high index of suspicion for RPC in the appropriate setting cannot be overemphasized.

Patients who have experienced recurrent episodes typically report 1-2 episodes of fevers, jaundice, and RUQ abdominal pain per year and a history of prior biliary surgery, endoscopic procedures, or percutaneous biliary drainage procedures.

Patients may present to the hospital with any sequelae of the complications of RPC, including gram-negative bacteremia/sepsis and organ failure. Perforations of the bile duct can occur with rupture into potential spaces, including the pericardium and the peritoneum. Acute pancreatitis is an infrequent but often-described consequence of recurrent bouts of pyogenic cholangitis. In patients presenting with acute pancreatitis, the pain may be in the epigastrium, as opposed to the RUQ. A pyogenic hepatic abscess may be one presentation of RPC, as is biliary malignancy.

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Physical

No specific physical findings are evident in RPC. The history is cardinal in prompting the diagnosis.

Patients often appear ill, frequently are jaundiced, and usually have tenderness in the RUQ of the abdomen. Not infrequently in RPC, upon careful physical examination, an enlarged tender gallbladder can be palpated in the RUQ.

Other findings are specific to local and systemic complications of RPC, which can include the following:

  • Rupture into the peritoneum can precipitate an acute abdomen.
  • Rupture or fistulization into the abdominal wall often presents with pus drainage from cutaneous fistulae.
  • Rupture into the pericardium may present with tamponade.
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Contributor Information and Disclosures
Author

Praveen K Roy, MD, AGAF Chief of Gastroenterology, Presbyterian Hospital; Medical Director of Endoscopy, Presbyterian Medical Group; Adjunct Associate Research Scientist, Lovelace Respiratory Research Institute

Praveen K Roy, MD, AGAF is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

Rajan Kanth, MD Hospitalist, Ministry Saint Joseph’s Hospital

Rajan Kanth, MD is a member of the following medical societies: American College of Physicians, Society of Hospital Medicine, Nepal Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

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 & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Anil Minocha, MD, FACP, FACG, AGAF, CPNSS 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; Clinical Professor, University of Mississippi School of Pharmacy

Anil Minocha, MD, FACP, FACG, AGAF, CPNSS is a member of the following medical societies: American Academy of Clinical Toxicology, American Society for Gastrointestinal Endoscopy, American Federation for Clinical Research, American Association for the Study of Liver Diseases, American College of Forensic Examiners Institute, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Patrick I Okolo III, MD, MPH, and previous coauthor Sam Yoselevitz, MD, to the development and writing of this article.

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