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Acute Cholangitis Clinical Presentation

  • Author: Timothy M Scott, DO; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Dec 27, 2015
 

History

In 1877, Charcot described cholangitis as a triad of findings of right upper quadrant (RUQ) pain, fever, and jaundice. The Reynolds pentad adds mental status changes and sepsis to the triad. A spectrum of cholangitis exists, ranging from mild symptoms to fulminant overwhelming sepsis. With septic shock, the diagnosis can be missed in up to 25% of patients. Consider cholangitis in any patient who appears septic, especially in patients who are elderly, jaundiced, or who have abdominal pain. A history of abdominal pain or symptoms of gallbladder colic may be a clue to the diagnosis.

Symptoms include the following:

  • Charcot's triad consists of fever, RUQ pain, and jaundice. It is reported in up to 50-70% of patients with cholangitis. However, recent studies believe it is more likely to be present in 15-20% of patients.
  • Fever is present in approximately 90% of cases.
  • Abdominal pain and jaundice is thought to occur in 70% and 60% of patients, respectively.
  • Patients present with altered mental status 10-20% of the time and hypotension approximately 30% of the time. These signs, combined with Charcot's triad, constitute Reynolds pentad.
  • Consequently, many patients with ascending cholangitis do not present with the classic signs and symptoms. [5]
  • Most patients complain of RUQ pain; however, some patients (ie, elderly persons) are too ill to localize the source of infection.

Other symptoms include the following:

  • Jaundice
  • Fever, chills, and rigors
  • Abdominal pain
  • Pruritus
  • Acholic or hypocholic stools
  • Malaise

The patient's medical history may be helpful. For example, a history of the following increases the risk of cholangitis:

  • Gallstones, CBD stones
  • Recent cholecystectomy
  • Endoscopic manipulation or ERCP, cholangiogram
  • History of cholangitis
  • History of HIV or AIDS: AIDS-related cholangitis is characterized by extrahepatic biliary edema, ulceration, and obstruction. The etiology is uncertain, but it may be related to cytomegalovirus or Cryptosporidium infections. The management of this condition is described below, although decompression is usually not necessary.
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Physical

In general, patients with cholangitis are quite ill and frequently present in septic shock without an apparent source of the infection.

Physical examination may reveal the following:

  • Fever (90%), although elderly patients may have no fever
  • RUQ tenderness (65%)
  • Mild hepatomegaly
  • Jaundice (60%)
  • Mental status changes (10-20%)
  • Sepsis
  • Hypotension (30%)
  • Tachycardia
  • Peritonitis (uncommon, and should lead to a search for an alternative diagnosis)
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Causes

In Western countries, choledocholithiasis is the most common cause of acute cholangitis, followed by ERCP and tumors.

Any condition that leads to stasis or obstruction of bile in the CBD, including benign or malignant stricture, parasitic infection, or extrinsic compression by the pancreas, can result in bacterial infection and cholangitis. Partial obstruction is associated with a higher rate of infection than complete obstruction.

Common bile duct stones

CBD stones predispose patients to cholangitis. Approximately 10-15% of patients with cholecystitis have CBD stones.

Approximately 1% of patients post cholecystectomy have retained CBD stones. Most CBD stones are immediately symptomatic, while some remain asymptomatic for years.

Some CBD stones are formed primarily rather than secondarily to gallstones.

Obstructive tumors

Obstructive tumors cause cholangitis. Partial obstruction is associated with an increased rate of infection compared with that of complete neoplastic obstruction. Obstructive tumors include the following:

Other causes

Additional causes of cholangitis include the following:

  • Strictures or stenosis
  • Endoscopic manipulation of the CBD
  • Choledochocele
  • Sclerosing cholangitis (from biliary sclerosis)
  • AIDS cholangiopathy
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Contributor Information and Disclosures
Author

Timothy M Scott, DO Chief Resident, Department of Emergency Medicine, Detroit Medical Center, Wayne State University School of Medicine

Timothy M Scott, DO is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Osteopathic Association, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

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.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Jeffrey A Manko, MD A ssistant Professor of Emergency Medicine, Director, Emergency Medicine Residency Program, Consulting Staff, Emergency Medicine Services, New York University/Bellevue Medical Center

Jeffrey A Manko, MD is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sally Santen, MD Program Director, Assistant Professor, Department of Emergency Medicine, Vanderbilt University

Sally Santen, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
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  2. Kashyap R, Mantry P, Sharma R, et al. Comparative analysis of outcomes in living and deceased donor liver transplants for primary sclerosing cholangitis. J Gastrointest Surg. 2009 Aug. 13(8):1480-6. [Medline].

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  8. Attasaranya S, Fogel EL, Lehman GA. Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis. Med Clin North Am. 2008 Jul. 92(4):925-60, x. [Medline].

  9. Rustemovic N, Cukovic-Cavka S, Opacic M, et al. Endoscopic ultrasound elastography as a method for screening the patients with suspected primary sclerosing cholangitis. Eur J Gastroenterol Hepatol. 2010 Jun. 22(6):748-53. [Medline].

  10. Iorgulescu A, Sandu I, Turcu F, Iordache N. Post-ERCP acute pancreatitis and its risk factors. J Med Life. 2013 Mar 15. 6(1):109-13. [Medline]. [Full Text].

  11. Zhang RL, Zhao H, Dai YM, et al. Endoscopic nasobiliary drainage with sphincterotomy in acute obstructive cholangitis: a prospective randomized controlled trial. J Dig Dis. 2014 Feb. 15 (2):78-84. [Medline].

  12. Sharma BC, Agarwal N, Sharma P, Sarin SK. Endoscopic biliary drainage by 7 Fr or 10 Fr stent placement in patients with acute cholangitis. Dig Dis Sci. 2009 Jun. 54(6):1355-9. [Medline].

  13. Itoi T, Kawai T, Sofuni A, et al. Efficacy and safety of 1-step transnasal endoscopic nasobiliary drainage for the treatment of acute cholangitis in patients with previous endoscopic sphincterotomy (with videos). Gastrointest Endosc. 2008 Jul. 68(1):84-90. [Medline].

  14. Park TY, Choi JS, Song TJ, et al. Early oral antibiotic switch compared with conventional intravenous antibiotic therapy for acute cholangitis with bacteremia. Dig Dis Sci. 2014 Nov. 59(11):2790-6. [Medline].

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  16. Zimmer V, Lammert F. Acute bacterial cholangitis. Viszeralmedizin. 2015 Jun. 31 (3):166-72. [Medline].

 
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Sonogram of dilated intrahepatic ducts.
CT scan of common bile duct occluded by stone. Image courtesy of David Schwartz, MD, New York University Hospital.
CT scan of 1-cm dilated common bile duct at portal triad. Image courtesy of David Schwartz, MD, New York University Hospital.
CT scan of dilated intrahepatic bile ducts. Image courtesy of David Schwartz, MD, New York University Hospital.
Algorithm for management of patients with acute cholangitis.
 
 
 
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