Cholangitis in Emergency Medicine Workup

  • Author: Adam J Rosh, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Apr 26, 2012
 

Laboratory Studies

  • CBC: Leukocytosis: In patients with cholangitis, 79% had a WBC greater than 10,000/mL, with a mean of 13.6. Septic patients may be leukopenic.
  • Electrolyte panel with renal function may be performed.
  • Calcium level is necessary to check if pancreatitis, which can lead to hypocalcemia, is a concern.
  • Expect liver function test results to be consistent with cholestasis, hyperbilirubinemia (88-100%), and increased alkaline phosphatase level (78%).
  • Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels are usually mildly elevated.
  • Prothrombin time and activated partial thromboplastin time: Do not expect either to be elevated unless sepsis is associated with disseminated intravascular coagulation or underlying cirrhosis exists. A coagulation profile may be required if the patient needs operative intervention.
  • C-reactive protein level and erythrocyte sedimentation rate are typically elevated.[3]
  • Blood cultures (2 sets): Between 20% and 30% of blood cultures are positive. Many exhibit polymicrobial infections.
  • Urinalysis result is usually normal.
  • Blood type, screen, and crossmatch: With urgent operating room dispatch, patients need to have blood available.
  • Lipase: Involvement of the lower CBD may cause pancreatitis and an elevated lipase level. One third of patients have a mildly elevated lipase level.
  • Pancreatic enzyme elevations suggest that bile duct stones caused the cholangitis, with or without gallstone pancreatitis.[6]
  • Biliary cultures (not performed in the ED): Send biliary cultures if the patient has biliary drainage by interventional radiology or endoscopy.
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Imaging Studies

  • Imaging studies are important to confirm the presence and cause of biliary obstruction and to rule out other conditions. Ultrasonography and CT scanning are the most commonly used first-line imaging modalities.
  • Ultrasonography is excellent for gallstones and cholecystitis. It is highly sensitive and specific for examining the gallbladder and assessing bile duct dilatation. However, it often misses stones in the distal bile duct.[7] Sonogram of dilated intrahepatic ducts. Sonogram of dilated intrahepatic ducts.
    • Transabdominal ultrasonography is the initial imaging study of choice.
    • Ultrasonography can differentiate intrahepatic obstruction from extrahepatic obstruction and image dilated ducts.
    • In one study of cholangitis, only 13% of CBD stones were observed on ultrasonography, but dilated CBD was found in 64%.
    • Advantages to sonography include the ability to be performed rapidly at the bedside by the ED physician, capacity to image other structures (eg, aorta, pancreas, liver), identification of complications (eg, perforation, empyema, abscess), and lack of radiation.
    • Disadvantages to sonography include operator and patient dependence, cannot image the cystic duct, and decreased sensitivity for distal CBD stones.
    • A normal sonogram does not rule out acute cholangitis.
  • Endoscopic retrograde cholangiopancreatography (ERCP) is both diagnostic and therapeutic and is considered the criterion standard for imaging the biliary system.
    • ERCP should be reserved for patients who may require therapeutic intervention.
    • Patients with a high clinical suspicion for cholangitis should proceed directly to ERCP.
    • ERCP has a high success rate (98%) and is considered safer than surgical and percutaneous intervention.
    • Diagnostic use of ERCP carries a complication rate of approximately 1.38% and a mortality rate of 0.21%. The major complication rate of therapeutic ERCP is 5.4%, and it has a mortality rate of 0.49%.
    • Complications include pancreatitis, bleeding, and perforation.
  • CT is adjunctive to and may replace ultrasonography. Spiral or helical CT improves imaging of the biliary tree. CT cholangiography uses a contrast agent that is taken up by the hepatocytes and secreted into the biliary system. This enhances the ability to visualize radiolucent stones and increases detection of other biliary pathology. CT scan of dilated intrahepatic bile ducts. Image CT scan of dilated intrahepatic bile ducts. Image courtesy of David Schwartz, MD, New York University Hospital.
    • Dilated intrahepatic and extrahepatic ducts and inflammation of the biliary tree are imaged.
    • Gallstones are poorly visualized with traditional CT scan.
    • Advantages of CT include the following:
      • Other pathologies that are causes or complications of cholangitis (eg, ampullary tumors, pericholecystic fluid, liver abscesses) can be imaged.
      • Pathology that must be distinguished from cholangitis also can be observed (eg, right-sided diverticulitis, papillary necrosis, some evidence of pyelonephritis, mesenteric ischemia, ruptured appendix).
      • Detection of biliary pathology with CT cholangiography approaches that of ERCP.
    • Disadvantages of CT include poor imaging of gallstones, allergic reaction to contrast, exposure to ionizing radiation, and diminished ability to visualize the biliary tree with elevated serum bilirubin level.
  • Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive imaging modality that is increasingly being used in the diagnosis of biliary stones and other biliary pathology.
    • MRCP is accurate for detecting choledocholithiasis, neoplasms, strictures, and dilations within the biliary system.
    • Limitations of MRCP include the inability for invasive diagnostic tests such as bile sampling, cytologic testing, stone removal, or stenting.
    • It has limited sensitivity for small stones (< 6 mm in diameter).
    • Absolute contraindications are the same as for a traditional MRI, which include the presence of a cardiac pacemaker, cerebral aneurysm clips, ocular or cochlear implants, and ocular foreign bodies. Relative contraindications include the presence of cardiac prosthetic valves, neurostimulators, metal prostheses, and penile implants.
    • The risk of MRCP during pregnancy is not known.
  • In general, abdominal films aid little in the diagnosis of acute cholangitis.
    • An ileus may be observed.
    • Between 10% and 30% of gallstones have a ring of calcium and, as a result, are radiopaque.
    • Films may show air in the biliary tree after endoscopic manipulation or if the patient has emphysematous cholecystitis, cholangitis, or a cholecystic-enteric fistula.
    • Air in the gallbladder wall indicates emphysematous cholecystitis.
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Other Tests

  • Biliary scintigraphy (hepatic 2,6-dimethyliminodiacetic acid [HIDA] and diisopropyl iminodiacetic acid [DISIDA])
    • HIDA and DISIDA scans are functional studies of the gallbladder.
    • Obstruction of the CBD causes nonvisualization of the small intestine. A HIDA scan with complete biliary obstruction does not visualize the biliary tree.
    • Advantages include its ability to assess function and positive results may appear before the ducts are enlarged sonographically.
    • One disadvantage is that high bilirubin levels (>4.4) may decrease the sensitivity of the study. Recent eating or no food in 24 hours also may affect the study. In addition, anatomic imaging for other structures is lacking. The study takes several hours, so it is not recommended in critically ill or unstable patients.
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Procedures

  • ED physicians generally do not perform procedures for cholangitis (eg, ERCP and transhepatic decompression).
  • If an obstruction is observed, ERCP provides direct visualization and potential treatment. It is best performed after 72 hours of antibiotics or after resolution of fever.
  • In unstable patients, a reasonable option for decompression of the biliary tract is percutaneous transhepatic cholangiogram and biliary drain. The biliary ducts are observed, even when no ductal dilatation is present.
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Contributor Information and Disclosures
Author

Adam J Rosh, MD  Assistant Professor, 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, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey A Manko, MD  Assistant 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.

Specialty Editor Board

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

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

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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 Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

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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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