Recurrent Pyogenic Cholangitis Clinical Presentation

Updated: Oct 01, 2019
  • Author: Praveen K Roy, MD, MSc; Chief Editor: Vinay K Kapoor, MBBS, MS, FRCSEd, FICS, FAMS  more...
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Patients may present with the following: (1) an acute attack of cholangitis, (2) a history of recurrent attacks of cholangitis typified by fevers, right upper quadrant (RUQ) abdominal pain, and jaundice, or (3) complications of pyogenic cholangitis. As the disease progresses, patients may develop cholangiocarcinoma and present with constitutional symptoms, including weight loss, easy fatigability, pruritus, and progressive jaundice. [3, 4]

Roughly one third of patients present with an initial episode of cholangitis. 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 recurrent pyogenic cholangitis (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.


Physical Examination

No specific physical findings are evident in recurrent pyogenic cholangitis (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, hepatomegaly or 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.