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Diagnostics
Disease
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Cholangitis General Cholangitis refers to an acute infection of the biliary tree, and has the potential to cause significant morbidity and mortality. It occurs secondary to stasis or obstruction of bile compounded by the presence of bacteria. Choledocholithiasis (stones in the common bile duct) has long been the most common cause of obstruction, however, strictures, tumors, or manipulation of the common bile duct may cause bile stasis, leading to the predisposition to bacterial infection of the biliary tree. The most common organisms associated with Cholangitis are those found in the gut (E Coli, Klebsiella, Enterobacter, Enterococci, and Group D Streptococci). Charcot recognized cholangitis in 1877 when he described what has come to be known as Charcot's Triad (Fever, Jaundice, RUQ pain). Reynolds and Dargon, in 1959, described a more severe form of the illness which included Charcot's Triad plus the addition of hypotension (septic shock) and mental status changes, thus coining the term Reynold's Pentad.
Cholangitis occurs relatively infrequently in the US, and as it most commonly associated with gallstones, the risk factors for development are essentially the same. Importantly, however, although the risk of gallstones is higher in women, than in men, cholangitis occurs equally in both sexes. Untreated, the mortality of cholangitis is high (13-88%). Characteristics associated with increased mortality include hypotension, acute renal failure, liver abscess, cirrhosis, and IBD. Clinical Presentation
A spectrum of cholangitis exists, from mild illness to fulminant, overwhelming sepsis. Charcot's Triad of fever, jaundice, and RUQ pain classically occur in up to 70% of patients presenting with illness, however, some patients (particularly the elderly) are too ill to localize the infection. A past medical history of gallstones, recent cholecystectomy, ERCP, or history of cholangitis are helpful in elucidating the diagnosis. Scleral icterus, fever, pruritis, and mild hepatomegaly all help support the diagnosis. The findings of mental status changes and hypotension indicate pregression of the disease to ascending cholangitis and warrants immediate care. Treatment Essential medical care for cholangitis includes the administration of broad spectrum antibiotics and correction of fluid and electrolyte abnormalities. Because of the high biliary pressures created by obstruction, the biliary secretion of antibiotics can become impaired. In these instances, decompression and drainage of the biliary system becomes tantamount. Endoscopic biliary drainage and decompression and transhepatic drainage have pretty much replaced surgery as the initial treatment for severe or overwhelming cholangitis. Surgical decompression is appropriate in patients for which endoscopic or transhepatic drainage is unsuccessful or unavailable.
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