Cholangitis - Indications, Types, and Treatment

Introduction:

Cholangitis is the swelling of the bile ducts or biliary tract. These bile ducts carry bile from the liver and gallbladder to the first part of the small intestine called the duodenum. The bile ducts get a bacterial infection or a blockage due to gallstones or unintentional blockage during surgery. These bile tracts swell and cause fever, pain, vomiting, color changes in the urine or stools, and other associated symptoms like low blood pressure. This condition is more prevalent in older adults and people who have a history of gallstones. Cholangitis can be ruled out with blood tests like liver function test, white blood cell count, bilirubin levels, and other imaging techniques like ultrasound, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP). Treatment for cholangitis includes antibiotic therapy and surgery in severe cases.

What Is Cholangitis?

Cholangitis is the inflammation of the bile ducts. Bile ducts or biliary tracts are tubes that connect the liver and gallbladder to the duodenum (first part of the small intestine). The gallbladder is a small organ on the right side of the upper abdomen that stores and releases bile to help in the digestion process. When there is a blockage or an infection in these connecting tubes called bile ducts, the ducts swell and cause various symptoms.

What Causes Cholangitis?

Cholangitis is caused by a bacterial infection or blockage of the connecting tubes called bile ducts. The infection can be due to one of these gram-positive bacteria like Escherichia coli, Enterobacter, Klebsiella, and gram-negative bacteria like Pseudomonas, Enterococcus, and anaerobes. The blockage is mainly due to gallstones (gallstones are small pieces of hardened bile that settle in the gallbladder), but it can also be due to a tumor, narrowing of the biliary tract after a surgical procedure, sclerosing cholangitis (an autoimmune disease), blood clots, swollen pancreas, backflow of bacteria, infections from the intestine or stomach, or after an endoscopic procedure when a liver or gallbladder is being checked. An endoscopic procedure is used to look for any blocks or any issues which cannot be ruled out externally in a particular organ using a small tube.

What Are the Types of Cholangitis?

• Acute Cholangitis: This type of cholangitis is also known as ascending cholangitis. It occurs when there is an infection in the junction between the bile duct and duodenum (the first part of the small intestine) and moves up or ascends, especially when there is already a blockage due to gallstone or stagnant bile. The small intestine has three parts, duodenum, jejunum, and ileum.

• Primary Sclerosing Cholangitis (PSC): The primary cause of this type of cholangitis is still unclear, but it can occurdue to an autoimmune disorder (when the body's immune system attacks its own body or organs) that causes inflammation followed by scar formation in the bile duct. This scar further narrows and hardens the duct, causing severe liver damage, leading to liver cirrhosis and other complications like cholangiocarcinoma (bile duct cancer). People with primary sclerosing cholangitis have associated inflammatory diseases like Crohn's disease or ulcerative colitis.

• Secondary Sclerosing Cholangitis (SSC): Secondary sclerosing cholangitis condition is similar to PSC, but the causes are specific. Conditions like stones in the bile duct, bile duct cancer, liver cancer, prostate cancer, damage to bile ducts during a surgical procedure, reduced blood supply to the bile ducts, and toxicity caused by chemotherapy are some of the known causes.

• Recurrent Pyogenic Cholangitis: It is also known as Hong Kong disease or Oriental cholangitis, which is a long-term, repetitive event of bacterial infectious cholangitis which is prevalent in people who live or lived in southeast Asia in the past. It occurs when an individual is malnourished or is exposed to bacterial or parasitic infections. This causes narrowing of the bile ducts both inside and outside the liver, and also pigmented stones appear in the biliary tree. A biliary tree is a system of vessels that channels secretions from the liver, pancreas, and gallbladder into the first part of the small intestine (duodenum).

What Are the Signs and Symptoms of Cholangitis?

1. Pain in the right upper side or middle part of the abdomen or stomach. The pain can spread to the backside or below the right shoulder blade.

2. Fever and chills.

3. Nausea and vomiting.

4. Dark color urine.

5. Clay-colored stools.

6. Jaundice - yellowish discoloration of the skin and eyes.

7. Lethargy.

8. Low blood pressure.

9. Changes in alertness.

Who Is at Risk?

1. People with a history of gallstones.

2. People with an autoimmune disease called sclerosing cholangitis.

3. People with the congenitally narrowed bile duct (bile duct will be narrow naturally during birth).

4. People who have traveled recently might have been exposed to parasites or bacteria.

5. People who have HIV (human influenza virus) infection.

6. People who underwent surgical procedures recently in and around the bile duct area.

7. People who are 50 years or older.

8. Pancreatic cancer.

9. Right side abdominal injury.

How Is Cholangitis Diagnosed?

• Blood Tests:

1) Liver Function and Enzyme Tests: This test reveals the liver status. It shows the levels of different enzymes like alkaline phosphatase (ALP), alanine transaminase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT), proteins like albumin (a protein made in the liver), prothrombin time (PT), total protein and bilirubin (a waste product made by the liver). The difference in the levels of any of these parameters indicates liver disease.

2) Complete Blood Count: A blood test to detect a wide range of infections or disorders when there is a difference in the normal levels of red blood cells, white blood cells, platelet count, and eosinophils

3) Bilirubin Levels: Discrepancy in the bilirubin level reflects liver disease.

• Imaging Technique

1) Ultrasound: An imaging technique that uses sound waves to show what is inside our body or a particular organ through an image.

2) Endoscopic Retrograde Cholangiopancreatography (ERCP): It involves the use of an X-ray with a long, thin, and flexible tube with a tiny camera called an endoscope to view the internal organs. A dye is injected into the veins, which highlights a specific organ to be viewed, and it reflects on an X-ray.

3) Magnetic Resonance Cholangiopancreatography (MRCP): This imaging technique uses magnetic resonance imaging to view bile ducts and pancreatic ducts without any intervention procedures.

How Is Cholangitis Treated?

• Antibiotics: Antibiotics like Penicillin, Ceftriaxone, Metronidazole, or Ciprofloxacin will be recommended for a few days.

• Endoscopy Surgery: Endoscopic surgery with minimal invasion, like balloon dilating the obstructed or blocked ducts, can be recommended.

• Biliary Drainage: Draining the stagnant bile and placing a small tube with numerous holes help in the better flow of the bile.

• Surgery: Surgical removal of the part of the duct that has been blocked. Placement of stents, a mechanical device that broadens the constricted part.

• Liver Transplant: In severe cases, liver transplantation is done.

• Symptomatic Approach: Associated symptoms like low blood pressure will be controlled with fluid infusions through veins, and pain killers will be recommended for abdominal pain.

What Are the Complications?

1. Liver Damage: Untreated cholangitis can cause liver cirrhosis (scarring), which can slow down liver function and result in liver damage and failure.

2. Enlarged Spleen: Spleen is enlarged as a result of the accumulation of old blood cells when the liver does not function properly and does not drain the toxins.

3. Enlarged Veins: Veins swell and burst when there is excess pressure in the veins in the stomach, caused by high blood pressure in the liver.

4. Sepsis: Acute cholangitis causes blood infection (sepsis), which affects other organs if left untreated.

What Is the Prognosis?

The prognosis relies on the cause of the cholangitis. A good prognosis is seen in early treatment with antibiotics, drainage, and widening of the obstructed duct. Females, individuals with acute renal failure, liver cirrhosis (liver scarring) patients, older adults, and people with bile duct obstruction due to a cancerous tumor show poor prognosis.

Conclusion:

Cholangitis can be life-threatening if not detected and treated early. Though it is a serious condition, regular liver health check-ups with blood tests and consulting a doctor if you have symptoms like fever, yellowish discoloration of skin or eyes, stomach pain, and changes in bowel movements can help detect the underlying condition early. Follow the doctor’s instructions promptly for a long and healthy life.