cholangitis



Overview

What is cholangitis?

Definition.

Cholangitis refers to an inflammatory disease that occurs in the biliary system and includes infectious and noninfectious cholangitis.

Non-infectious cholangitis, including primary sclerosing cholangitis and autoimmune cholangitis, is less common.

This article focuses on infectious cholangitis.

Types

According to the progress of the disease is divided into two categories: acute and chronic.

Acute cholangitis: it is an acute inflammation that occurs in the bile ducts inside and outside the liver. When acute cholangitis is complicated by purulent infection, it is called acute obstructive purulent cholangitis, also known as acute severe cholangitis.

Chronic cholangitis: Mostly from acute cholangitis extended.

Morbidity

Most common in middle-aged and elderly people, with no clear incidence data available.

Prevalent in people with a history of gallbladder and bile duct disease; middle-aged and elderly people aged 40 to 60 years old; people who have been drinking alcohol for a long time.

Questions you may be concerned about

What is the most typical clinical manifestation of cholangitis?

The typical clinical manifestations of acute and chronic cholangitis are not exactly the same.

Typical clinical manifestations of acute cholangitis are right upper abdominal pain, chills, high fever and jaundice. The degree of abdominal pain varies according to the location of the obstruction. Obstruction above the confluence of the right and left hepatic ducts usually has only mild abdominal pain, while patients with extrahepatic bile duct obstruction may show severe pain; the body temperature is often as high as 40℃ or more; and there are manifestations such as yellowing of the skin and sclera, etc. Chronic cholangitis may have moderate to high fever, jaundice, and chills.

Chronic cholangitis may have discomfort, distension or colic in the middle and upper abdomen, and the pain in the upper abdomen may be aggravated after eating greasy food.

Can primary biliary cholangitis be completely cured?

The prognosis of primary biliary cholangitis varies greatly. Most of the patients can be cured if ursodeoxycholic acid treatment is effective, while the prognosis of those with increased bilirubin and autoimmune disorders is poor.

Primary biliary cholangitis may be related to immune system diseases, genetic factors, the prognosis of the treated patients varies greatly, and it is generally accepted that increased bilirubin, accompanied by autoimmune disorders, and histologic prognosis suggests that the prognosis is poor.

What medications should I take for cholangitis?

Early mild cholangitis, the condition is not too serious, can be used first non-surgical treatment methods, including antispasmodic analgesics such as magnesium sulfate; fasting gastrointestinal decompression; high-dose broad-spectrum antibiotics combined use.

Commonly used second- and third-generation cephalosporins (e.g., cefuroxime, cefoperazone) and metronidazole, cefoperazone has a higher concentration in the bile and can be used as a preferred drug. Antibiotic therapy should be adjusted with bacterial culture and drug sensitivity testing. Surgical treatment should be considered if non-surgical treatment is not effective.

Etiology

Causes

Biliary obstruction and bacterial infection are the main causes of cholangitis attacks.

If the condition of acute cholangitis is not well controlled or curative treatment is not carried out, the disease will turn into chronic cholangitis if the disease is prolonged.

Bile duct obstruction

The bile ducts are divided into intrahepatic bile ducts and extrahepatic bile ducts. The biliary system has the function of secretion, storage, concentration and transportation of bile.

Bile duct stones, benign bile duct stenosis, malignant tumors of the bile duct can lead to biliary obstruction, and the stagnant bile continues to cause irritation to the surrounding bile ducts, leading to cholangitis.

Bacterial infection

When the biliary system is diseased, it can cause the bacteria in the bile to multiply, leading to biliary tract infection, resulting in the occurrence of acute cholangitis.

The causative bacteria are mainly gram-negative bacteria, of which Escherichia coli and Klebsiella are the most common. Among the gram-positive bacteria, enterococci are common. 25%-30% of acute cholangitis is combined with anaerobic infection.

Medical factors

Biliary examination and surgery (e.g., biliary anastomotic stricture, percutaneous hepatic perforation cholangiography, endoscopic retrograde cholangiopancreatography, and placement of endoprostheses) can cause injuries and bacterial infections in the biliary tract and lead to cholangitis.

Symptoms

Acute cholangitis

Typical symptoms

Right upper abdominal pain: the degree of abdominal pain varies according to the site of obstruction. Obstruction above the confluence of the right and left hepatic ducts usually has only mild abdominal pain, while patients with extrahepatic bile duct obstruction may show severe pain.

Chills and high fever: the patient’s body temperature is usually up to 40℃ or more.

Jaundice: the patient’s skin and sclera are yellow.

Chronic cholangitis

There may be discomfort, distension, or colic in the middle and upper abdomen.

Epigastric pain is aggravated after eating greasy food.

Complications

Infectious shock

If the infection is not controlled in time, the bacteria and toxins in the bile can retrograde into the blood, leading to severe bacteremia and septicemia, and even infectious shock, which manifests as high fever, apathy, etc., or even coma and death.

Bile duct stenosis

Repeated episodes of cholangitis can lead to scarring and narrowing of the bile ducts, manifesting as jaundice and intermittent dull pain in the upper abdomen.

Consultation

Department of Medicine

General Surgery

Seek medical attention if you experience epigastric discomfort, distension, or pain that worsens after eating greasy food.

Emergency Department

If you experience symptoms such as severe abdominal pain, high fever, or confusion, please go to the Emergency Department immediately.

Preparation for medical treatment

Preparing for medical treatment: registration, preparation of documents, common problems

Tips for seeking medical treatment

Keep a record of the symptoms and their duration for your doctor’s reference.

Try not to take painkillers by mouth before your visit to the emergency room, as this may affect the doctor’s judgment of your condition.

Preparation Checklist

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

What is the discomfort? How long has it lasted?

Is there any abdominal pain?

Has the epigastric pain worsened after eating fatty foods? What is the level of pain?

Any fever?

Any other discomfort?

Have you ever had a similar condition before?

Any history of intra- and extra-hepatic bile duct stones?

Have you had any examination or treatment? What is the effect?

What medications have you taken recently? Any history of drug allergies?

Test results for the past 6 months, which can be brought to the doctor’s office

Blood tests

Liver function, blood amylase

Coagulation Function

Abdominal ultrasound, abdominal CT, magnetic resonance cholangiopancreatography (MRCP)

Endoscopic retrograde cholangiopancreatography (ERCP)

Medication use in the last 3 months, if available in a box or package, bring it with you to the doctor’s office

Pain medications: ibuprofen, aspirin

Antibiotics: cefuroxime, levofloxacin, amoxicillin

Bile medications: ursodeoxycholic acid, obeticholic acid

Diagnosis

Diagnosis is based on

Medical history

History of recurrent biliary tract infections and/or biliary surgery.

May have recently undergone tests such as endoscopic retrograde cholangiopancreatography (ERCP).

Clinical manifestations

There may be abdominal pain in the right upper abdomen or subxiphoid region, high fever, chills, jaundice, nausea, and vomiting.

Pressure pain is present in the right upper or middle-upper abdomen.

Imaging examination

Ultrasonography has the advantage of being non-invasive and convenient and is the main method of diagnosing cholangitis.

Ultrasonography can detect bile duct dilatation and stones.

Note: Adjust the position during the examination as prescribed by the doctor.

CT examination can further determine the site of biliary obstruction, dilatation of bile ducts inside and outside the liver and the nature of lesions.

Precautions

MRCP can clearly show the extent and degree of dilatation of the bile ducts inside and outside the liver, and can provide more accurate judgment on stones, tumors and obstruction.

Precautions

The endoscope enters through the mouth, goes along the digestive tract to the duodenum, injects contrast agent from the opening of the duodenal papilla, and observes the structure of the pancreas and bile ducts together with ultrasonic endoscopy, CT and other means, and at the same time it can carry out relevant treatments such as stone removal and stent placement.

Contraindications: patients with severe cardiopulmonary and renal insufficiency; patients with acute pancreatitis or acute attack of chronic pancreatitis; patients allergic to iodine contrast agent.

Precautions: fasting for 6~8 hours before surgery; position adjustment as prescribed by the doctor during surgery; dry heaving, regurgitation and other manifestations may occur; please contact the doctor in time if there is fever, abdominal pain, vomiting blood, black stool after surgery.

Laboratory examination

Patients with cholangitis have elevated inflammatory response indicators (white blood cell count/C-reactive protein), which can confirm the presence of infection in the body.

Patients with acute severe cholangitis may have a decreased platelet count.

Cholangitis may lead to abnormalities in liver function, as evidenced by elevated total bilirubin and other markers.

Precautions

Patients with acute severe cholangitis may present with coagulation disorders, as seen by a prolonged clotting time.

The severity of acute cholangitis can be assessed.

Patients with moderate or severe cholangitis require biliary drainage, which may be accompanied by bile culture, the results of which can guide the use of antimicrobials.

Grading

According to the Tokyo Guidelines for Acute Biliary Tract Infections (2018 edition), acute cholangitis can be categorized as Grade I acute cholangitis, Grade II (moderate) acute cholangitis, and Grade III (severe) acute cholangitis based on symptoms and signs.

Grade III (Severe) Acute Cholangitis

Acute cholangitis combined with 1 or more of the following organ insufficiencies:

Cardiovascular dysfunction: hypotension requiring dopamine or norepinephrine therapy.

Neurologic dysfunction: impaired consciousness.

Respiratory dysfunction: oxygenation index (PaO2/FiO2) <300.

Renal dysfunction: oliguria, blood creatinine >176.8 μmol/L.

Hepatic dysfunction: prothrombin time-international normalized ratio (PT-INR) >1.5.

Hematopoietic dysfunction: platelet count <100×109/L.

Grade II (moderate) acute cholangitis.

Acute cholangitis combined with 2 of the following:

White blood cell count >12×109/L or <4×109/L.

Hyperthermia with temperature greater than or equal to 39°C.

Age ≥ 75 years.

Jaundice: total bilirubin ≥85.5 μmol/L.

Low protein: total serum protein or albumin <0.7 × upper limit of normal.

GradeⅠ Acute cholangitis

Acute cholangitis that does not meet the diagnostic criteria for Grade II (moderate) and Grade III (severe).

Differential Diagnosis

Pancreatitis

Similarities: Both have symptoms such as abdominal pain, nausea, vomiting, and fever.

Differences: Pancreatitis usually attacks after a full meal and alcohol consumption, manifested by pain in the whole abdomen, and elevated serum amylase or lipase can be seen in laboratory tests, which can be differentially diagnosed by CT examination.

Biliary Ascariasis

Similarity: both have abdominal pain.

Differences: biliary ascariasis is often a sudden sharp pain under the sword, paroxysmal aggravation, some patients can vomit roundworms, pain can be suddenly relieved, usually no obvious fever. It can be differentiated by imaging examination.

Treatment

Acute cholangitis is based on emergency relief of biliary obstruction, smooth drainage of bile ducts, infection control and anti-shock; chronic cholangitis is based on removing the cause of the disease.

Acute cholangitis

Supportive treatment

Establish intravenous access, replenish fluids, replenish effective circulating blood volume, and correct electrolyte disorders.

Patients with high fever are given ice blankets and other cooling treatments.

Hypotensive patients are given dopamine to elevate the pressure.

Antibacterial treatment

Mild: first or second generation cephalosporins (e.g. cefotiam) or fluoroquinolones (e.g. moxifloxacin, etc.) can be chosen.

Moderate and severe: combination of β-lactamase inhibitors (cefoperazone/sulbactam, ampicillin/sulbactam, etc.), third- and fourth-generation cephalosporins (cefoperazone, ceftriaxone, ceftazidime, etc.), and monocyclics (amitriptyline) may be chosen.

Bile culture results may further guide antimicrobial use.

Biliary drainage

Moderate or severe acute cholangitis requires immediate biliary drainage when supportive therapy and antimicrobial therapy alone are ineffective.

During the drainage treatment, it is necessary to pay attention to the proper fixation of the drainage tube, to avoid pressure, pulling and folding of the drainage tube, and to contact the doctor in time if the drainage tube is blocked.

Endoscopic biliary drainage is the first choice of drainage treatment for moderate and severe acute cholangitis, including transendoscopic retrograde cholangiopancreatography (ERCP) drainage and endoscopic nasobiliary drainage (ENBD).

Transendoscopic retrograde cholangiopancreatography (ERCP) drainage: stent placement and duodenal papillary sphincterotomy (EST) can be performed at the same time, and stones can be removed directly to resolve the obstruction at the same time as drainage. This treatment carries the risk of pancreatitis and is contraindicated in patients with coagulation disorders, cardiopulmonary or renal insufficiency, and acute attacks of pancreatitis.

Endoscopic nasobiliary drainage: it can carry out biliary flushing and imaging at the same time of drainage, and is suitable for patients with coagulation disorders. It is contraindicated for patients with stenosis of upper gastrointestinal tract and biliary tract obstruction, severe esophagogastric varices with bleeding tendency or severe gastroesophageal reflux who cannot tolerate surgery.

Suitable for patients with acute cholangitis due to failure of ERCP and ENBD, biliary obstruction caused by tumor, stone or stenosis at or above the hepatic hilum.

Contraindicated in the presence of coagulation disorders.

Patients who have failed endoscopic biliary drainage and PTCD may undergo open surgery and have a T-tube placed in the bile duct to drain the obstruction.

Chronic cholangitis

Chronic cholangitis and patients after complete control of acute biliary infection can be treated according to the cause of biliary obstruction.

For patients with stones causing biliary obstruction, cholecystectomy and biliary lithotripsy may be considered.

For patients with biliary tract obstruction caused by tumors, surgical resection and palliative treatment can be performed according to the situation.

Patients with biliary stenosis leading to biliary obstruction may be considered for choledocho-jejunostomy, biliary stenting, and biliary balloon dilatation treatment.

Prognosis

Cure

The prognosis of acute cholangitis is related to the severity of the disease and the timeliness of treatment. The prognosis is poorer if the disease is too severe and untimely treatment leads to infectious shock and multi-organ failure.

The prognosis of chronic cholangitis is directly related to the cause of the obstruction. Usually, the prognosis is better when timely treatment is given to those caused by stones and benign bile duct stenosis; the prognosis is worse for those caused by liver cancer and bile duct cancer.

Harmfulness

After the attack of cholangitis, bile cannot flow normally, if not corrected in time, biliary cirrhosis will be formed, which may lead to portal hypertension, ascites, liver and spleen enlargement and so on.

Cholangitis may also lead to narrowing of the hepatic bile ducts and repeated damage to the bile duct walls.

Acute severe cholangitis is not treated in time, the condition deteriorates quickly, infectious shock may occur, and severe cases may die in a short period of time.

Daily

Daily Management

Dietary management

Focus on a light and easily digestible diet with more nutritious food, such as milk, soy products, eggs, fresh vegetables and fruits, to speed up the body’s recovery.

Avoid spicy and stimulating foods, such as garlic and chili peppers.

Try to eat less high-fat food, such as fatty meat and animal offal.

Life management

Take more rest, you can walk appropriately according to your condition, etc. Avoid excessive exercise to aggravate the pain feeling.

Pay attention to dietary hygiene and prohibit smoking and drinking.

Follow-up

Follow up regularly according to the doctor’s instructions, and bring along your personal medical records, report card of medical consultation, laboratory tests, CT examination results and medication prescriptions.

If the symptoms do not decrease or even worsen, you need to consult the doctor promptly.

If there is any other discomfort, you should inform your doctor promptly.

Physical examination and abdominal CT may be done during the follow-up visit, so please prepare for this in advance.

Prevention

Prevention of biliary tract infection is the key

You should choose a low-salt and low-fat diet, and avoid high-fat, high-cholesterol, greasy food, as well as spicy and irritating food.