Ascending Cholangitis
Gallstone Disease Overview
Spectrum of Gallstone Disease Presentation
Be aware that gallstone disease can present as ANY of the following:
| Condition | Pathophysiology | Clinical and biochemical manifestations | Key investigations | Management |
|---|---|---|---|---|
| Cholelithiasis | Presence of gallbladder stone |
|
|
Elective laparoscopic cholecystectomy if symptomatic |
| Choledocholithiasis | Presence of common bile duct stone |
|
|
Bile duct clearance + laparoscopic cholecystectomy |
| Acute cholecystitis | Persistent cystic duct obstruction → gallbladder inflammation |
|
|
IV fluids + antibiotics → early laparoscopic cholecystectomy |
| Acute cholangitis | Common bile duct obstruction → ascending bacterial infection | Charcot’s triad:
|
|
IV antibiotics + urgent ERCP |
| Gallstone pancreatitis | Stone impacts at ampulla of Vater → pancreatic duct obstruction → pancreatitis |
|
|
Supportive (IV fluids, analgesia, optimise nutrition) → cholecystectomy after recovery |
Background Information
Definition
Ascending cholangitis is defined as a bacterial infection of the biliary tree, that occurs secondary to biliary obstruction
Aetiology and Pathophysiology
Most common cause of biliary obstruction in ascending cholangitis: [Ref]
- Choledocholithiasis (common bile duct stone) – most common
- Obstructing mass (e.g. cholangiocarcinoma, pancreatic adenocarcinoma)
- Benign or malignant biliary strictures
- Biliary stents
- Mirizzi syndrome (obstruction of the common hepatic duct due to extrinsic compression from a gallstone impacted in the cystic duct or gallbladder neck, often accompanied by local inflammatory changes)
Pathophysiology: [Ref]
- Biliary obstruction → bacteria ascend from the duodenum into the biliary system → colonisation and infection
- Most common organism: gram -ve enteric bacteria (e.g. E. coli, Klebsiella species)
Risk Factors for Gallstone Formation
Risk factors for gallstone formation can be divided according to the composition of the gallstone: [Ref]
| Cholesterol gallstone (most common) | 5 Fs
Other risk factors
|
| Pigmented gallstone | Causes of chronic haemolysis
Other causes
|
Complications
Key complications:
- Sepsis → septic shock → multiple organ dysfunction syndrome (esp. cardiovascular, renal and respiratory failure) – most important
- Pyogenic liver abscess
- Pericholecystic abscess
- Biliary strictures (may cause biliary cirrhosis from prolonged obstruction and infection)
Diagnosis
Diagnostic criteria: [Ref]
- Typical clinical features, and
- Systemic signs of inflammation, and
- Signs of cholestasis, and
- Confirmatory imaging findings
Clinical Features and Blood Tests
Typical textbook presentation (not always present): [Ref]
- Charcot’s triad (high specificity but poor sensitivity): fever + jaundice + RUQ pain
- Reynold’s pentad: Charcot’s triad + hypotension + altered mental status
Features of the diagnostic criteria: [Ref]
| Systemic signs of inflammation |
|
| Signs of cholestasis |
|
The classic table of biliary colic vs acute cholecystitis vs ascending cholangitis:
| Condition | Pain (RUQ / epigastric) | Signs of inflammation (fever / ↑ WCC / ↑ CRP) | Signs of biliary obstruction (jaundice / hyperbilirubinaemia) |
|---|---|---|---|
| Cholelithiasis (biliary colic) | Yes | No | No |
| Choledocholithiasis | Yes | No | Yes |
| Acute cholecystitis | Yes | Yes | No |
| Ascending cholangitis | Yes | Yes | Yes |
Imaging
1st line: abdominal ultrasound [Ref]
- Findings:
- Biliary duct dilatation
- Evidence of an underlying cause (e.g. stone, stricture, obstructing mass)
2nd line: MRCP / CT abdomen with IV contrast
- Consider if abdominal ultrasound has not detected common bile duct stones BUT suspicion remains
Management
Initial Management
Initial management involves supportive care: [Ref]
- IV fluid resuscitation as appropriate
- Empirical antibiotics (targeting enteric gram-negative and anaerobic organisms)
Definitive Management
Definitive management: biliary decompression via ERCP [Ref]
- Ideally it should be performed when patients are hemodynamically stable (after initial resuscitation)
Technically, ERCP is not routinely indicated in all patients with ascending cholangitis
- Mild (grade I) disease does NOT routinely require ERCP if there is improvement with supportive care and antibiotics. ERCP is reserved for those failed to respond to medical therapy
- Otherwise, non-mild disease (grade II-III) requires routine ERCP (urgency depends on severity)
However, exam questions typically expect one to choose ERCP as the “most appropriate management”. Unless the scenario specifies that the patient is responding well to medical therapy and declines any invasive intervention.
Secondary Prevention
Secondary prevention is achieved via prophylactic cholecystectomy [Ref]
- It is offered after an episode of gallstone-related cholangitis in patients who are clinically stable AND have an acceptable surgical risk
- NOT routinely offered to patient with non-gallstone (i.e. acalculous) aetiologies