Acute Cholangitis - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

The bile ducts are tubes that carry bile from the liver and gallbladder to the small intestine. Bile is a fluid that helps in the process of digestion. Acute cholangitis, also known as ascending cholangitis or simply cholangitis, is the inflammation of the bile duct system. Cholangitis is a medical emergency and can be life-threatening. Acute cholangitis occurs suddenly, and chronic cholangitis happens over a while. Some people develop cholangitis as an autoimmune condition.

What Are the Causes of Acute Cholangitis?

The causes of acute cholangitis include:

• Bacterial infection.

• Blockage of the bile duct due to gallstones.

• Blockages for some other reason.

• Tumors of the bile duct system.

• Narrowing of the bile duct after surgery.

• Infection of the blood (bacteremia).

Some other environmental causes of acute cholangitis include:

• Infection (bacteria, virus, or parasite).

• Smoking.

• Chemicals.

What Are the Risk Factors for Acute Cholangitis?

The risk factors of acute cholangitis include:

• It usually affects adults between the age of 30 and 50.

• Cholangitis can be a hereditary condition and can run in families.

• Persons with gallstones are at risk for cholangitis.

• Having an autoimmune disease like inflammatory bowel disease.

• Any recent procedures involving the bile duct area.

What Are the Symptoms of Acute Cholangitis?

The symptoms can vary from person to person. Charcot's cholangitis triad is a set of three findings of cholangitis: abdominal pain, jaundice, and fever. Reynold's pentad includes Charcot's triad and the presence of septic shock and confusion.

The most common symptoms of acute cholangitis include the following:

• Pain in the right upper abdomen.

• Fever.

• Chills.

• Nausea and vomiting.

• Dark urine.

• Clay-colored stools.

• Yellowing of the skin and eyes (jaundice).

• Hypotension.

• Lethargy.

• Elderly patients may present with symptoms like confusion in whom pain and jaundice will be absent.

How Is Acute Cholangitis Diagnosed?

• Physical Examination: The physician will perform a physical examination that reveals right upper quadrant tenderness, fever, and jaundice.

• Complete Blood Count: In the presence of infection, the white blood cell count increases.

• Liver Function Tests: This test is used to find whether the liver is functioning properly and whether the liver enzymes are within the normal range.

• Cholesterol Test: A cholesterol test can help diagnose gallstones, a risk factor for cholangitis.

• Blood Culture: This helps to identify a blood infection.

Imaging tests for acute cholangitis include:

• Ultrasound: This uses high-frequency sound waves to create images of the internal organs. For diagnosis of acute cholangitis, an ultrasound is done to create images of the liver, gallbladder, and bile duct.

• Computed Tomography (CT) Scan: A computed tomography scan involves using x-rays that create detailed cross-sectional images of the organs. During this procedure, a dye is also injected to show the areas of blockage in the bile ducts.

• Magnetic Resonance Cholangiopancreatography (MRCP): This procedure uses a magnetic field and radio waves to create images of the body. This procedure helps find gallstones or other blockages in the bile duct.

• Endoscopic Retrograde Cholangiopancreatography (ERCP): This procedure involves using x-rays and a long, thin, flexible tube attached to a camera called an endoscope. The endoscope is slowly inserted through the mouth and then forwarded into the esophagus, stomach, and intestine, and x-rays are taken to view the liver, gallbladder, and bile ducts. A dye is also injected during the procedure, which can show any blockages in the bile duct. This procedure also helps in opening the blockages of the bile ducts.

• Percutaneous Transhepatic Cholangiography (PTC): A needle is inserted into the skin to the liver and bile ducts. A dye is injected through this needle, and x-rays are taken to see any blockages. It is an invasive procedure and is the least frequently used.

How Is Acute Cholangitis Classified According to Severity?

Based on the severity, cholangitis is divided into three grades:

1) Grade I or Mild Acute Cholangitis: The patient has no organ dysfunction and responds well to antibiotic treatment.

2) Grade II or Moderate Acute Cholangitis: The patient does not have organ dysfunction and does not respond to antibiotic treatment. Grade II is positive when any two of the five conditions are present:

• Leukocytosis or leukopenia.

• High temperature.

• Elderly.

• Hyperbilirubinemia.

• Hypoalbuminemia.

3) Grade III or Severe Acute Cholangitis: The patient does not respond to initial medical treatment and has organ dysfunction.

How Is Cholangitis Treated?

Early treatment and diagnosis are necessary to prevent complications. In case of acute cholangitis caused by an infection, antibiotics such as Penicillin, Metronidazole, and Ciprofloxacin are given for ten days. Intravenous fluids are given.

The effective treatment of cholangitis is the removal of the biliary obstruction and drainage of the bile through the endoscopic retrograde cholangiopancreatography procedure. Balloon dilation opens the bile ducts and improves the bile flow. Gallstones are removed, and a stent is placed to open the bile ducts. Sometimes, surgery is done if other treatment methods are not applicable in which the blockages are removed, and the bile is drained to reduce the buildup of bile. Cholangitis can affect the process of digestion. So vitamin supplements like vitamins A, D, E, and K are given.

How to Prevent Acute Cholangitis?

Preventing cholangitis is not primarily possible. Since gallstones are the main reason for the blockage of bile ducts, preventing gallstones may help reduce the occurrence of cholangitis. Eating a high-fiber diet and regular exercise may help prevent the formation of gallstones. Since smoking can increase the risk of cholangitis, stopping smoking is necessary.

What Are the Complications of Acute Cholangitis?

Acute cholangitis can lead to serious, life-threatening complications if not treated correctly.

The complications include:

• Cirrhosis: Cholangitis can cause liver scarring, which can lead to liver failure.

• Gallstones: Bile fluid buildup can develop into stones which can cause pain and further infections.

• Sepsis: Acute cholangitis can cause sepsis (infection of the blood).

• Portal Hypertension: Liver cirrhosis can increase the blood pressure in the liver, which also increases the pressure of veins in the stomach.

Conclusion:

Acute cholangitis is a serious condition, and immediate treatment is required. Early diagnosis and proper treatment with antibiotics and removal of the blockage of the bile duct results in a good prognosis, and most people recover well from cholangitis. Cholangitis can lead to several health problems when untreated.