Acute cholangitis

Aetiopathogenesis:

• Organisms enter the biliary tree either from the GI tract via the duodenal papilla or by excretion in the bile after reaching the liver via the bloodstream.
• In the bile, these organisms multiply in the presence of an obstruction to cause inflammation
• In the Western world, the most common cause of this obstruction is a common bile duct stone(s)
• Infected bile in the biliary tree is potentially fatal because it may lead to septicaemia and hepatorenal failure.
• Long-term sequelae of repeated attacks of cholangitis include:
• Liver abscesses
• Secondary biliary cirrhosis
• Liver failure
• Portal hypertension

Clinical features:

• Charcot’s triad:
• Abdominal pain
• High fever with rigors
• Jaundice

• Past hx of biliary disease may be obtained
• The liver may be somewhat enlarged and tender

Investigation:

Full blood count:

• Leucocytosis

LFTs:

• Cholestasis (raised ALP)

Blood cultures:

• Positive in most instances

Ultrasound:

• Gallbladder stones
• Dilated duct
• Ductal stone (occasionally)

Mx:

Resuscitation with IV fluids and parenteral A/Bs are begun on a best guess basis. A prompt response will result in:

Relief of symptoms

Resolution of fever

Rapid reduction in jaundice

Failure to achieve this indicates the need for bile duct drainage by urgent ERCP. If possible, stones should be extracted, but effective biliary drainage is the first essential requirement. Rx of cholelithiasis can be deferred until the acute episode has settled.