Cholangitis Clinical Presentation

Updated: Nov 20, 2016
  • Author: Homayoun Shojamanesh, MD; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS  more...
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Presentation

History

A history of choledocholithiasis or recent biliary tract manipulation associated with fever (often with chills and rigors), 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.

According to Fujii et al, the 2007 Tokyo guidelines for the diagnosis and treatment of acute cholangitis were mostly acceptable. [4] However, classification into mild or moderate grade using the guidelines could be challenging, so it was necessary for clinicians to carefully distinguish organ dysfunction associated with cholangitis itself from dysfunction associated with the underlying disease in determining the severity of the disease. [4]

Similarly, Nishino et al found that the 2013 Tokyo guidelines for the diagnosis and treatment of acute cholangitis are practical, but they may underestimate some cases that necessitate urgent/early biliary drainage as mild disease. [5] The investigators developed a scoring system that took into consideration the following five predictors, which they indicate may improve identification of patients at high risk of needing urgent/early biliary drainage [5] :

  • Blood urea nitrogen level above 20 mg/dL
  • Platelet count below 120,000/μ L
  • Serum albumin level below 3.0 g/dL
  • The presence of systemic inflammatory response syndrome (SIRS)
  • Age of 75 years or older
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Physical

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

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Causes

The two main causes of cholangitis are biliary tract manipulation and common bile duct stones. [6] 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 [7] 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.

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