Cholangitis

Cholangitis is bacterial infection of the biliary tree. It is almost always secondary to biliary obstruction.

Choledocholithiasis is the most common cause. Others are malignant stricture, benign post-surgical stricture and a blocked biliary stent. Bacteria ascend from the duodenum and proliferate in stagnant, obstructed bile.

Cholangitis is a biliary sepsis syndrome. It is a medical emergency because it can progress rapidly to septic shock.

Charcot's triad: fever (often with rigors), right upper quadrant pain, and jaundice, present in a majority but not all cases. Reynolds' pentad adds hypotension and altered mental status, indicating progression to severe cholangitis with septic shock, a more ominous presentation carrying significantly higher mortality. Examination may reveal right upper quadrant tenderness and scleral icterus. Tokyo Guidelines severity grading (mild, moderate, severe, based on organ dysfunction) guides the urgency of biliary decompression.

FBC (leukocytosis), LFTs (cholestatic pattern, elevated bilirubin, alkaline phosphatase, and gamma-GT), blood cultures (essential, taken before antibiotics where possible, given the high rate of bacteremia), and lactate to assess for evolving sepsis. Abdominal ultrasound is the first-line imaging study, assessing for biliary duct dilatation and identifying gallstones, though it does not always identify the obstructing stone itself.

MRCP characterizes the biliary anatomy and obstruction more precisely without radiation, and CT assesses for complications or an alternative diagnosis if the picture is unclear. ERCP serves as both diagnostic confirmation and, more importantly, the therapeutic intervention.

Differentials include cholecystitis (fever and right upper quadrant pain without jaundice in most cases, gallbladder rather than duct pathology), hepatic abscess, right lower lobe pneumonia (can cause referred right upper quadrant pain), and other intra-abdominal sepsis.

This is a time critical emergency needing the same simultaneous approach as any sepsis presentation (see Sepsis entry). Resuscitate with IV fluids and take blood cultures before antibiotics where feasible.

Give prompt broad spectrum IV antibiotics covering gram negative enteric organisms and anaerobes, for example piperacillin-tazobactam, or a third generation cephalosporin combined with metronidazole. Start within the hour, in line with sepsis bundle principles.

Source control through biliary decompression is essential and should not be delayed once the patient is stabilized. Urgent ERCP with sphincterotomy and stone extraction or stent placement is the treatment of choice. Timing is generally within 24 to 48 hours for moderate disease, and emergent for severe disease with septic shock or failure to respond to initial resuscitation.

Percutaneous transhepatic biliary drainage is an alternative when ERCP is not technically feasible or immediately available.

Once the acute episode has resolved, treat the underlying cause. This is most commonly cholecystectomy for choledocholithiasis after duct clearance, or further workup and management of any underlying malignant stricture.

Referral: this is a medical emergency requiring urgent gastroenterology or hepatobiliary surgery involvement for ERCP or biliary drainage. Patients meeting Reynolds' pentad or otherwise showing signs of septic shock need ICU or HDU level care.