Acute cholecystitis and cholangitis are 2 of the 3 main emergencies of the biliary tract and can be life-threatening if appropriate treatment is not initiated promptly. Both present with abdominal pain and are frequently seen in clinical practice. The primary focus of this summary is cholangitis. Cholecystitis is discussed in further detail separately.
Acute cholangitis is a condition of acute inflammation and infection in the common bile duct. The bile is normally sterile in nature. Stasis of bile from obstruction of the common bile duct from a stone, stent, parasites, or cancer promotes bacterial growth that then spreads and ascends to the biliary duct, resulting in acute ascending cholangitis.
Demographics and risk factors of cholangitis and acute cholecystitis: Sex – Women are more likely to develop gallstones because of higher estrogen levels. For the same reason, pregnancy and hormone replacement therapy increase the risk of gallstones. Approximately 25% of women older than 60 have gallstones.
Age – Gallstones are unusual in children. In cases when they occur, they are commonly pigment stones. The following conditions put children at a higher risk of having gallstones:
Spinal injury
History of abdominal surgery
Sickle cell disease
Impaired immunity
Intravenous nutrition
Ethnicity / geography – Gallstones are related to diet, particularly fat and cholesterol; hence, their incidence varies in different populations and parts of the world. Hispanics, Europeans, and Americans have a higher risk of gallstones than people of Asian or African descent. Those of Asian or African descent who do develop gallstones have a higher risk of developing brown pigment stones.
Obesity and weight changes – In obesity, the liver overproduces cholesterol, which increases the risk of gallstone formation. Rapid weight loss is also a risk factor for the development of cholesterol gallstones.
Pregnancy – Increase in cholesterol saturation of bile and impaired gallbladder contraction during pregnancy predispose to formation of cholesterol stones or biliary sludge.
Genetics – Having a family member with gallstones increases one's risk. Mutation of gene ABCG8 increases the risk of gallstone formation.
AIDS – Biliary disease occurs via 2 mechanisms in patients with AIDS:
AIDS cholangiopathy (commonly due to Cryptosporidium or cytomegalovirus)
Drugs – Many drugs increase the formation of gallstones. Examples include fibrates, oral contraceptive pills, thiazides, ceftriaxone, and octreotide.
Ascariasis – This is a geographical risk factor in regions such as China and Southeast Asia. It can cause cholecystitis, cholangitis or hepatic abscess, or even pancreatitis.
Other parasites – In Asia, Clonorchis sinensis, Opisthorchis felineus, Opisthorchis viverrini, and Fasciola hepatica are associated with acute and relapsing cholangitis. Clonorchis and Opisthorchis parasitic infections are known causes of cholangiocarcinoma in Asia.
Clinical manifestations of cholangitis: Signs and symptoms include Charcot's triad and Reynolds' pentad.
Charcot's triad:
Acute cholangitis was first described by Charcot in 1877 as hepatic fever.
Typical signs and symptoms of acute cholangitis include intermittent fever with chills, right-upper-quadrant (RUQ) pain, and jaundice.
Fever and abdominal pain are seen in 80% of patients, while jaundice is seen less frequently, in 60%-70% of cases.
Reynolds' pentad:
Described by B. M. Reynolds in 1959.
In addition to components of Charcot's triad, patients also have hypotension and confusion / altered mental status.
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.
MRCP image demonstrates numerous fililng defects in the dilated extrahepatic biliary tree. Purulent material was found during ERCP. Findings consistent with cholangitis.
