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Cholangitis - Indications, Types, and Treatment

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Cholangitis is the inflammation of the bile duct caused by a bacterial infection or blockage of the biliary tract by one or more gallstones. This article describes everything about cholangitis.

Written by

Dr. Janani R S

Medically reviewed by

Dr. Mian Shah Yousaf

Published At August 11, 2022
Reviewed AtJuly 11, 2023

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.

Frequently Asked Questions

1.

What Are the Triggering Factors of Cholangitis?

Certain factors like a history of gallstones, autoimmune diseases like sclerosing cholangitis, constriction of the common bile duct, and HIV (human immunodeficiency virus) increase the risk of getting cholangitis. In addition, sometimes, parasite infections also lead to cholangitis.

2.

What Are the Symptoms of Cholangitis?

Pain in the right upper region of the abdomen, fever, chills, nausea, vomiting, dark-colored urine, clay-colored stools, lethargy, low blood pressure, and lethargy are the signs and symptoms that occur in patients with cholangitis.

3.

What Diet Needs to Be Followed in Patients With Cholangitis?

A well-balanced diet with equal proportions of protein, carbohydrates, vitamins, and fibers is recommended. However, it is important to include calcium-rich foods and foods rich in vitamin D. It is advisable to avoid undercooked meats and seafood like shellfish and fish.

4.

Is Cholangitis a Type of Autoimmune Disease?

Primary sclerosing cholangitis and secondary sclerosing cholangitis occur due to autoimmune disorders. It is called an autoimmune disorder when the immune system attacks its own healthy cells and organs. This leads to inflammation and scarring of the bile ducts.

5.

What Is the Difference Between Cholecystitis and Cholangitis?

Cholangitis is the swelling or inflammation of the bile duct, while cholecystitis is the swelling or inflammation of the gallbladder. Cholangitis and cholecystitis are caused by infections, gallstones, tumors, bile duct obstruction, reduced blood supply due to problems in the blood vessels, etc.

6.

What Are the Outcomes of Cholangitis?

Liver damage, enlarged spleen, enlarged veins, and sepsis are complications of cholangitis. The liver cells are subjected to scarring, leading to liver damage. Spleen enlargement occurs when there is a build-up of unremoved blood cells due to liver dysfunction. Due to high pressure in the liver, the veins burst and cause trouble. Also, infections result due to acute cholangitis.

7.

What Is the Recovery Time After Cholangitis Treatment?

Cholangitis is a serious condition that requires treatment at the right time. Patients with cholangitis undergo endoscopic retrograde cholangiography, and some patients undergo percutaneous transhepatic cholangiography with early diagnosis. However, the recovery rate is good with early detection and medical intervention.

8.

Is Cholangitis Treatable?

Cholangitis is treated with antibiotics like Penicillin or Ciprofloxacin to reduce the risk of infections. Then further treatment like endoscopically enlarging the narrowed bile duct and surgical removal of the blocked part of the bile duct is done. Also, a symptomatic approach like managing low blood pressure with fluid infusions and painkillers for abdominal pain is recommended.

9.

Can One Live Long With Cholangitis?

The survival rate of cholangitis is around five to twelve years. Also, the median survival rate in symptomatic patients from diagnosis is around 7.5 years, and asymptomatic patients live up to 16 years from the time of diagnosis.

10.

Can Cholangitis Be Life-Threatening?

Acute cholangitis that occurs in a short period of time is life-threatening. It occurs due to an obstruction in the biliary tree combined with infections due to gallstone obstruction or biliary stricture. Early detection and treatment can prevent these complications.

11.

Can Cholangitis Lead To Sepsis?

Since there is no endothelial lining between the bile canaliculi and the liver capillary cells, the infection spreads fast. The bile canaliculi is a thin tubular structure that receives bile from the hepatocytes. Hepatocytes are liver cells. Infections resulting from bile duct blockage easily enter the liver and cause sepsis, leading to infections in multiple organs.

12.

What Are the Causes of Sclerosing Cholangitis?

Sclerosing cholangitis occurs due to an autoimmune reaction. When the body's own immune system attacks its healthy cells and organs, it is called an autoimmune condition. However, the exact causes of this autoimmune disorder are unclear.

13.

What Is the Symptom of Primary Sclerosing Cholangitis?

The early symptoms of primary cholangitis are fatigue, pain in the belly region, itching, jaundice, and skin and eyes becoming yellow. As the disease progresses, weight loss occurs, night sweats, fever, chills, enlarged liver, and enlarged spleen develop.

14.

What Causes an Emergency in Acute Cholangitis?

Acute cholangitis occurs in a short span of time. It is caused by obstruction of gallstones in the common bile duct, which results in infections. It also appears when there is an infection between the duodenum and the bile duct. This infection makes the patient critically ill. In addition, the infection is spread to other body parts and leads to life-threatening complications.

15.

How Can Cholangitis Be Prevented?

Cholangitis cannot be prevented, but the symptoms can be controlled by detecting the disease early and getting appropriate treatment. However, regular check-ups and visiting the doctor when initial symptoms appear will prevent the severity of the condition.

16.

What Causes Recurrent Pyogenic Cholangitis (RPC)?

Recurrent pyogenic cholangitis (RPC) is also called Hongkong disease, as it occurs in or occurred in people who lived in southeast Asia in the past. It occurs when a malnourished person is exposed to parasitic infections. This leads to constriction of bile ducts both inside and outside the liver.
Dr. Mian Shah Yousaf
Dr. Mian Shah Yousaf

Medical Gastroenterology

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