Laboratory Studies

Diagnostic testing in the workup of recurrent pyogenic cholangitis (RPC) includes the following:

Complete blood count: A leukocytosis with a left shift is typical in patients with pyogenic cholangitis.
Liver function tests: Aminotransferases, serum bilirubin, and alkaline phosphatase typically are elevated in patients with RPC. As with most biliary problems, no predictive or discriminant levels are available to help guide a diagnosis. In other words, any abnormal values in the appropriate clinical setting should prompt a suspicion of RPC, regardless of the degree of liver function test abnormality.
Prothrombin time: This may become prolonged if persistent cholestasis with consequent fat malabsorption and vitamin K deficiency is present. This is important to exclude because hypoprothrombinemia can impact the safety of invasive procedures and is easily correctible with parenteral vitamin K in this setting.
Blood cultures: These are mandatory because many patients are bacteremic. The blood culture results often help guide antibiotic choice.
Ova and parasites: Clonorchis or Opisthorchis infection frequently is associated with RPC and should be sought and treated when present.

Noninvasive imaging studies

Noninvasive imaging studies include transabdominal ultrasonography (US), computed tomography (CT) scanning, and magnetic resonance cholangiopancreatography (MRCP).

US is the preferred initial test during the primary workup. This imaging modality may demonstrate segmental biliary dilatation, hepatolithiasis, and liver abscesses, if present. Ultrasonography findings often determines the choice of supplemental axial imaging techniques.

CT scanning may demonstrate centrally dilated bile ducts with peripheral tapering. Cholangiohepatitis has a predilection for the left lobe of the liver, and predominantly left-sided findings should prompt consideration of this diagnosis in patients from endemic areas. Other potential findings on CT scans include bile duct stones and pyogenic liver abscesses.

The role of MRCP in the investigation of biliary disease continues to evolve in spite of the poor availability of magnetic resonance imaging (MRI) facilities in many regions of the world where recurrent pyogenic cholangitis (RPC) is endemic. MRI produces axial images and can be performed to evaluate the portal and hepatic venous system. Note the following:

MR cholangiography has replaced invasive endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography as the imaging modality of choice for delineating the biliary tree.
In a study of 45 patients with RPC who underwent direct cholangiography and MR cholangiography, MR cholangiography demonstrated 100% of all dilated segments, 96% of all strictures, and 98% of all calculi, whereas direct cholangiography demonstrated significantly less, reportedly 44% of all strictures and 45% of all calculi.
The role of MRCP is complementary to direct cholangiography, as MRCP, at present, does not offer any therapeutic opportunities.^{[5, 6, 7]}

MRI has been effective in differential diagnosis of malignant versus benign hepatic masses.^[8]

Invasive imaging techniques

Cholangiography in the management of RPC is pivotal.

The choice of endoscopic (ie, ERCP) versus percutaneous cholangiography (PTC) hinges on the patient's anatomy and general health status and on the availability of local expertise.

Very often, a combination of both techniques is necessary to achieve complete ductal clearance of stones and to ensure that drainage of the biliary tree has been optimized.

Treatment & Management

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Author

Praveen K Roy, MD, MSc Clinical Assistant Professor of Medicine, University of New Mexico School of Medicine

Praveen K Roy, MD, MSc is a member of the following medical societies: Alaska State Medical Association, American Gastroenterological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Rajan Kanth, MD Gastroenterologist, WellSpan Health

Rajan Kanth, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Nepal Medical Association, Society of Hospital 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.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chief Editor

Vinay K Kapoor, MBBS, MS, FRCSEd, FICS, FAMS Professor of Surgical Gastroenterology, Mahatma Gandhi Medical College and Hospital (MGMCH), Jaipur, India

Vinay K Kapoor, MBBS, MS, FRCSEd, FICS, FAMS is a member of the following medical societies: Association of Surgeons of India, Indian Association of Surgical Gastroenterology, Indian Society of Gastroenterology, Medical Council of India, National Academy of Medical Sciences (India), Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Additional Contributors

Anil Minocha, MD, FACP, FACG, AGAF, CPNSS Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center; Clinical Professor, University of Mississippi School of Pharmacy

Anil Minocha, MD, FACP, FACG, AGAF, CPNSS is a member of the following medical societies: American Academy of Clinical Toxicology, American Society for Gastrointestinal Endoscopy, American Federation for Clinical Research, American Association for the Study of Liver Diseases, American College of Forensic Examiners Institute, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Patrick I Okolo III, MD, MPH, and previous coauthor Sam Yoselevitz, MD, to the development and writing of this article.