What Is Recurrent Pyogenic Cholangitis?
Recurrent pyogenic cholangitis can be defined as repeated attacks of bacterial cholangitis along with intraductal pigmented stone formation and intrahepatic and extrahepatic bile duct strictures and obstruction.
Bacterial cholangitis is the inflammation of the biliary tree or bile duct system caused by bacteria such as Escherichia coli. The bile duct system is responsible for the transport of bile, a fluid helpful in digestion, from the liver and gallbladder to the intestine. Intraductal pigmented stones are dark-colored stones made up of bilirubin and calcium salts formed in the gallbladder and moved to the bile duct or formed in the bile duct itself. Intrahepatic and extrahepatic strictures are the blocked bile ducts leading to the buildup of bile in the liver, causing jaundice.
What Are the Other Names of Recurrent Pyogenic Cholangitis?
Recurrent pyogenic cholangitis is known by multiple names like oriental cholangiohepatitis, primary hepatolithiasis, oriental cholangitis, hong kong disease, and oriental infestation cholangitis.
What Are the Risk Factors of Recurrent Pyogenic Cholangitis?
The probability of men and women suffering from recurrent pyogenic cholangitis is equal. It usually affects patients in their third or fourth decades of life. It is commonly seen in patients who reside in or immigrated from Southeast Asia.
What Are the Signs and Symptoms of Recurrent Pyogenic Cholangitis?
The most evident signs and symptoms of recurrent pyogenic cholangitis:
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Increased body temperature (fever).
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Yellow coloration of skin and sclera as in jaundice.
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Pain in the upper right part of the abdomen.
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Increased levels of white blood cells (leukocytosis).
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High levels of alkaline phosphatase.
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Elevated levels of bilirubin in the blood.
What Are the Causes of Recurrent Pyogenic Cholangitis?
The accurate cause of the condition is unknown. But some strong relationship with parasites such as Ascaris lumbricoides and Clonorchis Sinensis and bacteria like Escherichia coli was noticed. Other possible reasons are nutritional deficiencies and low socioeconomic status.
What Is the Pathology of Recurrent Pyogenic Cholangitis?
Inflammatory and fibrotic changes in the walls of the bile duct are caused by the constant recurring infestation of the biliary system by parasites. This leads to stricture formation in the bile ducts, which leads to the accumulation of bile in the liver (bile stasis) and intrahepatic stones. This will ultimately result in diffuse biliary cirrhosis or focal liver fibrosis.
How to Diagnose Recurrent Pyogenic Cholangitis?
Diagnosis of recurrent pyogenic cholangitis starts with the doctor taking the medical history carefully and conducting a detailed patient examination.
1. Blood Tests: Blood tests prescribed by the doctor are:
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Complete Blood Count (CBC) - May detect microcytic anemia and neutrophilia.
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Liver Function Test - To check for increased levels of gamma-glutamyl transferase (gamma GT), bilirubin, and alkaline phosphatase.
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Kidney Function Test - To check for raised urea and creatinine levels.
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Coagulation Studies - This test measures the blood’s ability to clot and how long it takes to clot.
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Serum Lipase - To measure the amount of lipase in the body. Lipase is necessary to maintain normal digestive and cells function.
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Peripheral Blood Culture - To check for the presence of bacteria like E.coli.
2. Ultrasound: Ultrasound of the abdomen of the patient is useful as it makes it easier to visualize intraductal calculi and intrahepatic and extrahepatic biliary dilations. Ultrasound of the abdomen is also useful in the diagnosis of the complication of recurrent pyogenic cholangitis. Ultrasound is an important test for follow-up patients.
3. CT (Computed Tomography) Scan: The CT scan will provide similar details as ultrasound but with more clarity on the pathologies present there. It is easier to detect hepatolithiasis through a CT scan.
4. ERCP (Endoscopic Retrograde Cholangiopancreatography): It is an invasive diagnostic procedure as well as a treatment procedure for recurrent pyogenic cholangitis.
5. MRCP (Magnetic Resonance Cholangiopancreatography): It is a non-invasive imaging technique for the diagnosis of recurrent pyogenic cholangitis. MRCP is considered superior to endoscopic retrograde cholangiopancreatography (ERCP) and ultrasound and CT scans for visualizing the bile duct strictures and intrahepatic pigmented stones.
What Are the Complications of Recurrent Pyogenic Cholangitis?
Some of the complications of recurrent pyogenic cholangitis are:
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Biliary Cirrhosis: It is the inflammation and destruction of the bile duct. It occurs due to prolonged obstruction or narrowing of the bile duct or closure of the bile duct.
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Cholangiocarcinoma: This is the malignant growth of the cells of the bile duct system. This complication is seen in approximately five percent of the patients with recurrent pyogenic cholangitis.
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Pancreatitis: It is the inflammation of an organ that lies behind the stomach in the upper abdomen, which is the pancreas.
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Acute Kidney Injury: It is a condition in which the kidneys suddenly are unable to filter waste from the blood. This complication can occur within a few hours or a few days. This can be fatal for the patient.
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Septicemia: It is an infection that happens when bacteria enter the bloodstream and spread. It is the most extreme response of the body in response to recurrent pyogenic cholangitis.
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Hepatic Abscess (Pyogenic): A hepatic abscess is a pus-filled pocket that occurs because of a bacterial infection within the liver.
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Portal Hypertension: Portal vein is the blood vessel that supplies blood to the liver. Increased blood pressure in this vein is called portal hypertension.
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Chronic Liver Disease: It can be defined as the gradual destruction of liver tissue and deterioration of liver functions over time.
What Is the Treatment of Recurrent Pyogenic Cholangitis?
During the treatment of patients with recurrent pyogenic cholangitis, the team of doctors that play an important role is gastroenterologists, surgeons, and interventional radiologists. The aim of the treatment procedure is to clear the biliary tree of calculi and eliminate the bile stasis to prevent repeated sudden attacks of cholangitis and further stone formation. The treatment involves antibiotic therapy for sudden attacks of cholangitis, stricture dilation, removal of stones, biliary bypass, biliary drainage, liver resection, and liver transplantation.
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ERCP (Endoscopic Retrograde Cholangiography): As already mentioned in the previous section that it is an invasive procedure of treatment. It is preferred for extractable stones and for stricture dilation. Stone removal through this procedure can be achieved completely in more than 90 % of patients with extrahepatic lithiasis. For stricture dilation, metal stents are not recommended as they have a low long-term patency rate.
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PTC (Percutaneous Transhepatic Cholangiography): This procedure is useful when the peripheral ducts are obstructed.
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Surgical Intervention: This involves segmental hepatic resection, biliary bypass procedure, and liver transplantation. Resection of segmental ducts with calculi can be performed laparoscopically and will have little effect on hepatic function. Resection of atrophic segments also eliminates the complication of malignancy. The goal of the biliary bypass procedure is to eliminate bile stasis and repeated stone formation in the bile ducts. Repeated episodes of cholangitis may cause hepatic parenchymal injury in the patients, which often leads to hepatic failure. In the case of patients with liver failure, a liver transplant is the best and the only option. In liver transplantation, an affected liver is replaced with a healthy donor liver surgically.
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Interventional Radiology: It plays a pivotal role in percutaneous biliary drainage of infected segments of the bile duct, pigmented stone removal, and balloon dilation of biliary strictures.
Conclusion
Recurrent pyogenic cholangitis is a disease that often requires repeated surgical, medical, and radiological treatment. Even after definitive treatment, the chances of recurrence of the condition are very high. Radiological findings also play a key role in the diagnosis and management of the condition. It is important for patients who are once diagnosed with recurrent pyogenic cholangitis to go for check-ups regularly.
