Recurrent Pyogenic Cholangitis

Recurrent pyogenic cholangitis is chronic hepatolithiasis characterised by intrahepatic pigment stones, biliary strictures and repeated bacterial cholangitis.

Repeated obstruction and infection produce ductal dilatation, hepatic segmental atrophy, liver abscesses and progressive fibrosis.

Longstanding disease increases the risk of intrahepatic cholangiocarcinoma. (

The disease often affects the left lateral segments and right posterior sector but may be bilateral.

Patients have recurrent episodes of:

• Fever
• Right upper quadrant or epigastric pain
• Jaundice

Between acute attacks they may have chronic cholestatic liver abnormalities or recurrent abdominal discomfort.

Complications include liver abscess, secondary biliary cirrhosis, biliary sepsis and cholangiocarcinoma.

MRCP: define intrahepatic stones, strictures, segmental ductal dilatation and hepatic atrophy.

CT is useful for liver abscess, atrophy and suspected malignancy.

Acute cholangitis

Treat sepsis immediately and decompress the obstructed biliary system.

ERCP is particularly useful when stones or sludge involve the common bile duct or major central ducts. It allows sphincterotomy, stone extraction and temporary stenting.

Percutaneous transhepatic access is useful for peripheral intrahepatic stones and strictures that are inaccessible endoscopically.

Antibiotic treatment can begin with:

Piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion, adjusted for renal function.

Definitive treatment

The aim is not merely to treat each infection. Remove stones and correct the anatomical source of recurrent bile stasis.

For disease limited mainly to accessible central ducts, repeated endoscopic or percutaneous clearance may provide satisfactory control.

Anatomical hepatectomy is particularly appropriate for:

• Unilateral disease
• Segmental or lobar hepatic atrophy
• Severe intrahepatic stricturing
• Recurrent liver abscess
• Large persistent stone burden
• Suspected or proven cholangiocarcinoma.

Resecting the affected liver removes both stones and the strictured ducts responsible for recurrent disease.

Bilateral diffuse hepatolithiasis is more difficult and often requires combined endoscopic, percutaneous and operative clearance.

Recurrent cholangitis after apparently successful treatment should trigger repeat imaging for residual stones, recurrent stricture or developing cholangiocarcinoma.