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Cholangitis

Overview

Cholangitis is an inflammation of the bile ducts, which can disrupt the flow of bile from the liver to the intestines. It is often a serious condition requiring prompt medical attention.

  • Acute cholangitis (ascending cholangitis): Caused by bacterial infection, often due to bile duct obstruction.
  • Primary sclerosing cholangitis (PSC): Chronic, progressive disease leading to scarring and narrowing of bile ducts. Often associated with inflammatory bowel disease (IBD).
  • Secondary sclerosing cholangitis: Resulting from a secondary cause like infection, trauma, or ischemia. 
  • IgG4-related cholangitis: Autoimmune condition, often linked with IgG4-related disease.
  • Recurrent pyogenic cholangitis: Common in East Asia, characterized by recurrent infections with stone formation.

There are many causes and risk factors for this condition, these include:

  • Infections:
    • Bacterial infections (e.g., E. coli, Klebsiella, Enterococcus)
    • Parasites (e.g., liver flukes)
  • Obstructions:
    • Gallstones
    • Bile duct strictures
    • Tumours (e.g., cholangiocarcinoma)
  • Autoimmune:
    • IgG4-related cholangitis, PSC
    • Iatrogenic:
    • Post-surgical or post-endoscopic procedures (e.g., ERCP)
    • History of IBD (e.g., ulcerative colitis in PSC)

Multiple symptoms exist depending on the type of disease. These have been enumerated below.

Acute cholangitis (Charcot's Triad):

  • Fever and chills
  • Right upper quadrant abdominal pain
  • Jaundice

Obstructive ascending cholangitis (Reynolds' Pentad):

  • Fever and chills
  • Right upper quadrant abdominal pain
  • Jaundice
  • Hypotension (low blood pressure)
  • Altered mental status.

Chronic cholangitis (e.g., PSC):

  • Fatigue
  • Pruritus (itching)
  • Progressive jaundice
  • Weight loss

Multiple types of diagnostic modalities are available cholangitis; these include:

  • Blood tests:
    • Liver function tests: Elevated ALP, GGT, AST, ALT, and bilirubin levels
    • Complete blood count (CBC) test: Leukocytosis (high white blood cell (WBC) counts
    • Autoimmune marker analysis: Elevated IgG4 and ANCA (in PSC)
  • Imaging:
    • Ultrasound: Detects bile duct dilation
    • MRCP (Magnetic resonance cholangiopancreatography): Non-invasive visualisation of bile ducts
  • ERCP (Endoscopic retrograde cholangiopancreatography): For diagnosing and treating cholangitis
  • Microbiological studies: Blood cultures in suspected infection

Treatments vary depending on the type of cholangitis; the same have been enumerated below.

  • Acute cholangitis:
    • Antibiotics: Broad-spectrum targeting gram-negative and anaerobic bacteria.
    • Biliary decompression: Via ERCP or percutaneous drainage if obstructed
    • Supportive care (intravenous (IV) fluids, pain medication)
  • Primary sclerosing cholangitis (PSC):
    • No curative treatment; focus on symptom control.
    • Ursodeoxycholic acid (UDCA) may help bile flow.
    • Liver transplant in advanced cases.
  • IgG4-related cholangitis: Steroids or other immunosuppressants
  • Recurrent pyogenic cholangitis: Antibiotics and removal of stone
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