Cholangitis

Cholangitis is a severe bacterial infection and a form of complicated gallstone disease characterised by infection of the biliary tree secondary to stasis secondary to an obstruction of the common bile duct, usually a gallstone, called choledocholithiasis. It's characterised by Charcot's triad of fever, abdominal pain, and jaundice. Urgent treatment with source control and antibiotics is important. It may cause sepsis.

Patients can present with choledocholithiasis which has not yet been complicated by an infection.

Clinical features

Cholangitis usually presents with Charcot’s triad of fever, abdominal pain, and jaundice. Patients are usually ill-looking and may be septic.

Diagnosis and evaluation

Laboratory tests show evidence of cholestasis, especially hyperbilirubinaemia, and elevated inflammatory parametres. Obtaining blood cultures is important.

Imaging (usually ultrasound or MRCP) is indicated to visualise the obstruction, but if the clinical features make the diagnosis obvious one proceeds directly to ERCP, which can both visualise the obstruction and often treat it.

Treatment

Urgent treatment of cholangitis is important and involves antibiotics and source control.

Broad spectrum antibiotics are indicated until culture data is available. In Norway, ampicillin + gentamycin + metronidazole is used.

Source control is achieved by ERCP, which can remove the stone or obstruction, decompress the biliary tree, and place a stent in the common bile duct if necessary. It can also collect samples for culture. Should ERCP fail, one can drain bile pecutaneously.

Following resolution of the acute infection, the underlying cause of the biliary obstruction must be treated. In case of choledocholithiasis, cholecystectomy is indicated to prevent future attacks.