Contents
Infections involving the biliary system and leading to inflammation and obstruction of the biliary ducts
- GASTROENTEROLOGIC EMERGENCY
History
Dr Jean-Martin Charcot, working at the Salpêtrière Hospital in Paris, France, is credited with early reports of cholangitis, as well as his eponymous triad, in 1877. He referred to the condition as “hepatic fever” (fièvre hépatique). Dr Benedict M. Reynolds, an American surgeon, reignited interest in the condition in his 1959 report with colleague Dr Everett L. Dargan, and formulated the pentad that carries his name. It remained a condition generally treated by surgeons, with exploration of the bile duct and excision of gallstones, until the ascendancy of ERCP in 1968. ERCP is generally performed by internal medicine or gastroenterology specialists. In 1992 it was shown that ERCP was generally safer than surgical intervention in ascending cholangitis.

Etiology
Cholangitis:
- Primary sclerosing cholangitis (PSC)
- Secondary cholangitis: Ascending/suppurative cholangitis (M/C)
- Immune cholangitis: IgG4-associated cholangitis (IAC)
Ascending cholangitis:
- Choledocholithiasis (M/C cause)
- Congenital factors
- Post-operative factors (bile duct injury, bilio-enteric anastomosis strictures, sump syndrome)
- Inflammatory factors (parasitic infection, oriental cholangitis)
- Malignant strictures (bile duct, gallbladder, ampullary, pancreatic malignancy)
- Duodenal tumours
- Pancreatitis
- External compression, e.g. pericholecystic inflammatory changes, Mirizzi syndrome
- Papillary stenosis
- Duodenal diverticulum/Lemmel syndrome
Pathophysiology
Characterized by acute inflammation and infection of the bile duct system with increased bacterial loads (biliary infection) and high intraductal pressure levels (biliary obstruction) favouring bacterial and endotoxin translocation into the vascular and lymphatic drainage (concept of cholangiovenous and cholangiolymphatic reflux, respectively).
In conjunction with an increased permeability of the acutely inflamed biliary epithelium, the stage is set for potentially fatal complications such as biliary sepsis and hepatic abscess.

Charcot’s triad:
- Intermittent fever (90% cases)
- Right upper quadrant (RUQ) pain
- Jaundice (60-70% cases)
Reynolds’ pentad (indicative of ongoing biliary sepsis):
- Charcot’s triad
- Lethargy/mental confusion
- Septic shock
Diagnosis
Diagnostic criteria:

Imaging
- Abdominal ultrasound (USG)
- Endoscopic ultrasound (EUS)
- Magnetic resonance cholangiopancreatography (MRCP)
- CT-scan
- Endoscopic retrograde cholangiography (ERCP) (GOLD STANDARD): Complete assessment of a ductal tree, showing the presence of obstructive lesions and stenosis


Management
Treatment is directed at 2 main pathophysiologic components of acute cholangitis: biliary infection (systemic antibiotic treatment) and obstruction (biliary drainage)
In addition, appropriate supportive care has to be administered, in more severe cases in an intensive care setting with the option of providing adequate organ support if necessary.
Hospitalization is usually considered necessary even for patients with mild acute cholangitis.

Antibiotic treatment:
- IV fluid resuscitation
- Antibiotics: Ticarcillin + clavulanante (Timentin) or piperacillin + tazobactam (Tazocin)
Biliary drainage:
- Surgical drainage
- Percutaneous transhepatic biliary drainage (PTBD)
- Endocscopic drainage (FIRST-LINE)
- EUS-guided biliary drainage (EUS-BD) (FIRST LINE THERAPY)
- EUS-guided choledo-choduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided gallbladder drainage (EUS-GBD)
- ERCP
- EUS-guided biliary drainage (EUS-BD) (FIRST LINE THERAPY)


Supportive care:
More important in severe cases
- Invasive monitoring
- Intensive care setting
- Inotropic and ventilation support