MD Notes

creation date: 2025-12-24 23:52
tags: Pathologies

Ascending Cholangitis

Background

Definitions

Ascending cholangitis or acute cholangitis refers to a life-threatening condition caused by an ascending bacterial infection of the biliary tree.

Etiology

The cause of ascending cholangitis is from bacterial infection of the bile ducts. The predisposing factor for cholangitis requires an obstruction of biliary flow.

The most common cause of biliary obstruction is choledocholithiasis. Other causes include:

  • Benign or malignant strictures of the biliary ducts
  • Pancreatic cancer
  • Ampullary adenoma or cancer
  • Porta hepatis tumour
  • Parasites (Clonorchis sinensis/Chinese fluke, Fasciola hepatica), roundworm (Ascaris lumbricoides), tapeworm (Taenia saginata)
  • Biliary sludge deposits due to stent obstruction
  • Gallstone impaction in the neck of the gallbladder or cystic duct leading to compression of CBD or CHD (Mirizzi syndrome)
  • Peri-ampullary diverticulum of the duodenum (Lemmel syndrome)
  • AIDS

Pathogens implicated in ascending cholangitis are gram-negative and anaerobic organisms, the most common of which are:

  • E. coli
  • Klebsiella
  • Enterobacter
  • Pseudomonas
  • Citrobacter

Additionally, iatrogenic introduction of bacteria commonly occurs following ERCP.

Pathogenesis

In normal physiology, bile duct epithelium secretes IgA which acts as an anti-adherent factor towards bacteria allowing for bile flow to flush pathogens out of the ducts.

In the setting of biliary obstruction, elevated intra-biliary pressure exceeds the bacteriostatic capabilities of the epithelium resulting in inflammation and infection.

Complete obstruction can lead to increased bacteria and endotoxins within the vascular and lymphatic drainage systems further increasing the risk of bacteremia.

Clinical Presentation

Signs & Symptoms

The presentation of cholangitis can range greatly based on severity with the most severe being severe sepsis or septic shock.

Symptoms include:

  • Fever
  • Chills
  • Malaise
  • Rigors
  • Generalized abdominal pain
  • Jaundice
  • Pruritus
  • Pale stools

A number of clinical tools can be used:

Charcot triad
Sensitivity: 25%, specificity: 95%

  • RUQ abdominal pain
  • Fever
  • Jaundice

Reynolds pentad
Sensitivity: 5%, specificity: very high, not quantified

  • Charcot triad
  • Hypotension
  • Altered mental status

Note that owing to the low sensitivity, clinical suspicion should be maintained despite not meeting the clinical tools.

History & Physical Exam

Ensure to elicit medical history including:

  • Cholelithiasis (PMHx and FHx)
  • Recent cholecystectomy or ERCP
  • Prior history of cholangitis
  • History of AIDS

Consider evaluating for severe sepsis/septic shock.

Risk factors

  • Increased triglyceride intake
  • Non-active/sedentary lifestyle
  • BMI >30
  • Rapid weight loss

Diagnosis

Criteria

Diagnosis of ascending cholangitis is made if evidence of the three components are present:

Systemic inflammation:

  • Fevers and/or shaking chills
  • Lab evidence (eg. abnormal WBC, increased serum CRP)
    Cholestasis:
  • Elevated total bilirubin (≥34 mcmol/L)
  • Abnormal LFTs (ALP, GGT, ALT, AST; >1.5x ULN)
    Imaging:
  • Biliary dilatation
  • Evidence of etiology (eg. presence of stone, stricture, stent)

Work-up

Laboratory studies

  • CBC
  • Electrolytes and creatinine
  • Complete metabolic panel
  • Prothrombin time/INR
  • Blood culture and sensitivity

Imaging
In patients with Charcot’s triad and abnormal liver tests, ERCP is indicated to confirm diagnosis and provide drainage.

In other patients, abdominal ultrasound is used for CBD dilatation or stones. If normal, a CT abdomen is performed.

Differential

Acute cholecystitis:

  • May have fever and abdominal pain
  • Should not have significantly elevated bilirubin or ALP unless there is secondary cholestasis
  • Normal CBD on imaging
    Biliary leak:
  • Complication of direct bile duct injury
  • PMHx of laparoscopic cholecystectomy
  • Contained, loculated collections in gallbladder fossa on imaging
    Acute pancreatitis:
  • Acute onset epigastric abdominal pain
  • Elevated serum lipase or amylase 3x ULN
    Liver abscess:
  • Differentiated by ultrasound and/or CT

Red Flags / Complications

Uncontrolled bacteremia can lead to sepsis and septic shock.

Management

Treatment of ascending cholangitis should be done in-patient allowing admission to hospital. The exact management may vary based on severity but consist of:

  • IV fluids
  • Correction of electrolyte abnormalities
  • Pain control
  • Monitoring for organ dysfunction and septic shock
  • Empiric antibiotics

Antibiotics
Regimens should include antimicrobials against enteric streptococci, coliforms, and anaerobes.

Biliary drainage
ERCP is the preferred modality of treatment. This may include:

  • Drainage
  • Stone extraction
  • Stent insertion

In some cases, endoscopic ultrasound guided percutaneous drainage may be necessary if ERCP is not feasible.

Management of predisposing cause
Depending on the cause, further treatment may be necessary.

  • Gallstones - elective cholecystectomy after resolution
  • Benign biliary stricture - endoscopic therapy or surgery

References

Tools / Guidelines

Additional Reading

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