Cholangitis in Emergency Medicine Clinical Presentation

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.

• 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.^[4]
• 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.

• 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)

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.

• 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 cause cholangitis. Partial obstruction is associated with an increased rate of infection compared with that of complete neoplastic obstruction.

  • Pancreatic cancer
  • Cholangiocarcinoma^[5]
  • Ampullary cancer
  • Porta hepatis tumors or metastasis
• Additional causes of cholangitis include the following:

  • Strictures or stenosis
  • Endoscopic manipulation of the CBD
  • Choledochocele
  • Sclerosing cholangitis (from biliary sclerosis)
  • AIDS cholangiopathy
  • Ascaris lumbricoides infections