Secondary Cholangitis - Causes, Symptoms, and Treatment

Creator: Dr. Mahalpure Neha Sanjay
Published: 2023-02-22T18:34:03

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Secondary cholangitis is a type of cholangitis with a known etiology. Read to know more about secondary cholangitis.

Written by

Dr. Mahalpure Neha Sanjay

Medically reviewed by

Dr. Jagdish Singh

February 22, 2023

March 13, 2023

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Contents

What Is Cholangitis?
What Are the Types of Cholangitis?
What Causes Secondary Cholangitis?
What Are the Symptoms of Secondary Cholangitis?
How Is Secondary Cholangitis Diagnosed?
What Is the Differential Diagnosis of Secondary Cholangitis?
How Is Secondary Cholangitis Treated?

What Is Cholangitis?

Inflammation of the bile duct system that carries bile from the liver and gallbladder is known as cholangitis; bacteria most commonly cause this infection.

What Are the Types of Cholangitis?

American liver foundation included cholangitis as a liver disease and classified it as follows:

Progressive bile duct destruction causes primary biliary cholangitis or primary biliary cirrhosis.

Primary Sclerosing Cholangitis: It is a chronic liver disease characterized by scarring and inflammation of the bile duct. Patients with primary sclerosing cholangitis generally present with draining of bile through the gall bladder.
Secondary Cholangitis: It is a chronic biliary disease that causes obliteration, inflammation, and fibrosis of the bile duct accompanied by progressive destruction, which leads to biliary cirrhosis.

According to the symptoms, cholangitis is classified as:

Acute Cholangitis - Symptoms occur over a short period; onset is sudden.
Chronic Cholangitis - Symptoms are present for years and progress slowly.

What Causes Secondary Cholangitis?

Some of the most common causes of cholangitis include:

1. Gallstones: These stones obstruct the bile duct system.

2. Autoimmune Disease: Diseases like primary sclerosing cholangitis affect the bile system.

3. Other Causes :

Tumor.
Blood clots.
Inflamed pancreas.
Parasitic infection.
Bacterial infection.
Recurrent pancreatitis.
Surgical or blunt abdominal trauma.
Intra arterial chemotherapy.

But the etiology and the causes of secondary cholangitis differ from that of cholangitis. The most common causes of secondary cholangitis are longstanding biliary obstruction, ischemic injury to the biliary tree, and surgical trauma to the bile duct.

Other causes leading to secondary cholangitis are the following.

Intraductal stone disease.
Surgical trauma to the abdomen.
Blunt abdominal trauma.
Intra-arterial chemotherapy.
Recurrent pancreatitis.

What Are the Symptoms of Secondary Cholangitis?

Patients with cholangitis present with a wide range of symptoms which can be divided as follows:

Early Symptoms:

Fatigue.
Xerostomia.
Xeropthalmia.
Itching.

Long-Standing Symptoms:

Pain in the right side of the upper abdomen.
Fever.
Chills.
Yellowish discoloration of sclera and skin.
Nausea and vomiting.
Clay-colored stools.
Dark urine.
Low blood pressure.
Lethargy.
Night sweats.
Disorientation.
Ascites.
Weight loss.
Forgetfulness.

Secondary cholangitis has no initial symptoms other than abnormal liver function test results. However, bile flow is reduced as the disease progresses. Jaundice, itching, and upper abdominal discomfort are the clinical symptoms. Most secondary cholangitis patients have an ascending liver infection and recurring bacterial bile duct infection episodes.

How Is Secondary Cholangitis Diagnosed?

As mentioned above, secondary cholangitis has a pain similar to other disorders like gallstones; thus, diagnostic tests must be carried out to rule out the cause and confirm the diagnosis.

Blood Test:

Complete blood count.
Liver function test.
Blood culture.
Anti-mitochondrial antibody test.
Cholesterol test.

Imaging Tests:

Ultrasound.
Computed tomography.
Magnetic resonance cholangiopancreatography (MRCP).
Endoscopic retrograde cholangiopancreatography.
Percutaneous transhepatic cholangiography.

What Is the Differential Diagnosis of Secondary Cholangitis?

Other disorders that present similar symptoms are as follows:

IgG4-related sclerosing cholangitis.
AIDS-related cholangiopathy.
Ischemic cholangiopathy.
Eosinophilic cholangitis.
Primary sclerosing cholangitis (PSC).

How Is Secondary Cholangitis Treated?

Treatment of secondary cholangitis is wholly based on the underlying cause and the severity of the disease, but treating secondary cholangitis becomes more accessible as the disease presents with a known cause or evident medical history.

The line of treatment is as follows:

Treating symptoms.
Monitoring liver function.
Procedures to clear the blocked bile duct.

1. Treating Symptoms: This is considered the first line of treatment, where a patient is prescribed higher antibiotics like Penicillin, Ceftriaxone, Metronidazole, or Ciprofloxacin, for around ten days to overcome symptoms. In cases where the patient is hospitalized, these antibiotics can also be administered intravenously. This mode of treatment is effective when the condition is diagnosed in the early stages of the disease and is not very severe.

In cases with chronic cholangitis, antibiotics are of the least importance as they do not improve the symptoms. In such cases, Ursodeoxycholic acid, a liver-protective drug, is prescribed. This drug helps in improving the bile flow but does not improve cholangitis.

2. Draining Bile Duct: In cases where antibiotics are ineffective, a more invasive form of treatment is considered, which includes drainage of the bile duct; this can be done by endoscopic surgery or open procedure. Endoscopic surgery is preferred as it is less invasive and has a shorter recovery period.

3. Endoscopic Therapy: It is performed by dilating a balloon to open the duct and improve bile flow. This procedure helps in improving the condition and prevents the worsening of symptoms. The procedure's disadvantage is that it must be carried out repeatedly. The patient might be required to be put under general anesthesia and is sometimes intubated to protect the airway.

4. Percutaneous Therapy: The procedure is similar to endoscopic therapy but is performed through the skin; the patient is administered tranquilizers before the procedure. And the site of insertion through the skin is anesthetized.

5. Surgery: It is an invasive procedure where the affected area is removed, or a stent is placed to drain the bile duct; surgery is performed under general anesthesia.

6. Liver Transplant: A liver transplant is the only treatment available in severe cases where any other treatment is ineffective or worsens the patient's condition.

7. Rehabilatory Care: Secondary cholangitis, even if treated, weakens the body and affects the overall health of an individual due to its long-duration of disease; therefore, even when necessary treatment is provided patient requires adjuvant care, which includes:

Nutrition: Cholangitis affects digestion and nutritional absorption; therefore, one must prescribe vitamin supplements along with the treatment to maintain health and faster recovery.

Calcium Supplements: As osteoporosis is one of the symptoms reported by patients with secondary cholangitis, vitamin D and calcium supplements must be taken to improve bone density and strengthen the bones.

Patients with secondary cholangitis often present with portal hypertension; therefore, blood pressure in the liver should be repeatedly monitored and treated.

Conclusion:

Secondary cholangitis is a type of cholangitis with known underlying causes; the disease is caused due to biliary obstruction and presents a classic symptom of abdominal pain in the upper right quadrant. Other symptoms include loss of appetite, nausea, vomiting, forgetfulness, weakness, and weight loss. The diagnosis of the condition is made by clinical examination and laboratory investigations, including complete blood count, bile test, urine analysis, and radiographic imaging like ultrasound. Secondary cholangitis is curable when diagnosed early, and treatment includes antibiotics and endoscopic therapy. Still, more severe cases require a liver transplant.

Frequently Asked Questions

1. How Do Primary and Secondary Cholangitis Differ From One Another?

Primary cholangitis, also known as primary sclerosing cholangitis (PSC), is a chronic inflammatory disease that primarily affects the bile ducts inside and outside the liver. It is characterized by progressive inflammation, scarring, and narrowing of the bile ducts. Secondary cholangitis refers to inflammation of the bile ducts that is caused by an underlying condition or factor, such as an infection or obstruction. It is often a result of an infection ascending from the intestines or gallbladder, as in the case of bacterial cholangitis.

2. Which Are the Stages of Cholangitis?

Cholangitis is typically categorized into three stages based on the severity and progression of the condition.
Stage 1: Acute Cholangitis:
The initial stage of cholangitis is characterized by acute inflammation of the bile ducts. Common symptoms include abdominal pain, jaundice, fever, and chills.
Stage 2: Progression to Sepsis
If left untreated, acute cholangitis can progress to a more severe stage known as sepsis (widespread inflammation throughout the body).
Stage 3: Complications
In the advanced stages of cholangitis, various complications can arise due to persistent infection and inflammation. These complications include liver abscess (collection of pus within the liver), biliary sepsis, and septic shock.

3. What Distinguishes Cirrhosis From Cholangitis?

Cirrhosis is a chronic condition characterized by progressive scarring and damage to the liver tissue. It is not a specific disease but rather a consequence of various liver diseases, such as chronic hepatitis, alcohol-related liver disease, or non-alcoholic fatty liver disease. Cirrhosis primarily affects the liver itself, leading to impaired liver function. The bile ducts, which are the tubes that carry bile from the liver to the small intestine, become inflamed in cholangitis. Cholangitis primarily affects the bile ducts, causing symptoms related to bile flow disruption and potential complications.

4. Does Cholangitis Cause Liver Failure?

Cholangitis can give rise to various complications that can adversely affect liver function and contribute to liver failure. These complications may include portal hypertension (increased pressure in the portal vein system), biliary sepsis (widespread infection), hepatic encephalopathy (brain dysfunction due to liver disease), and hepatorenal syndrome (kidney dysfunction in advanced liver disease). These conditions can collectively impair liver function and lead to liver failure.

5. Is There Any Treatment for Cholangitis?

Acute cholangitis, which is often caused by an infection or obstruction, can generally be treated effectively with appropriate medical interventions. Primary cholangitis, such as primary sclerosing cholangitis (PSC), is a chronic condition with no known cure. However, management and treatment can help control the symptoms, slow the progression of the disease, and prevent complications. The curability of secondary cholangitis depends on the underlying cause. If the underlying factor, such as an infection or obstruction, is identified and effectively treated, the cholangitis can be cured.

6. What Types of Bacteria Cause Cholangitis?

Cholangitis is often caused by bacterial infections ascending from the intestines or gallbladder. The bacterium E. coli is typically found in the intestines. In cases of cholangitis, it can ascend from the intestines to the bile ducts and cause infection. Enterococcus bacteria, including Enterococcus faecalis and Enterococcus faecium, can be responsible for cholangitis, especially in individuals with prior biliary interventions or underlying conditions. Klebsiella is another bacterium commonly found in the gastrointestinal tract. It can also ascend to the bile ducts and cause infection, particularly in individuals with underlying conditions that compromise the immune system or bile flow. Streptococcus bacteria, such as Streptococcus viridans, can occasionally cause cholangitis.

7. What Kind of Pain Is Experienced in Cholangitis?

Pain associated with cholangitis is typically located in the upper right quadrant of the abdomen, which is the area where the liver and gallbladder are located. Cholangitis-related pain is often continuous and may persist for hours or even days. It is not typically relieved by rest or changes in body position.

8. Which Blood Test Can Diagnose Cholangitis?

When diagnosing cholangitis, several blood tests can be performed to assess liver function, detect signs of inflammation, and identify markers of infection. These include liver function tests, complete blood count, C-reactive protein, blood cultures, and coagulation tests.

9. What Is the Recommended Drug for Cholangitis?

Ceftriaxone and Cefotaxime are commonly used as initial empirical antibiotic therapy for cholangitis. They have broad-spectrum activity against many bacteria commonly associated with cholangitis, including Escherichia coli, Klebsiella species, and Enterobacter species. Antibiotics such as Ciprofloxacin or Levofloxacin are often used in cases where there is a high suspicion of gram-negative bacteria, particularly when there is a history of recent biliary intervention or hospital-acquired infection.

10. Which Vitamin Deficiency Causes Cholangitis?

Cholangitis itself is not typically caused by a specific vitamin deficiency. Cholangitis is primarily the result of bacterial infection, obstruction of the bile ducts, or underlying conditions such as primary sclerosing cholangitis (a chronic inflammatory disease that primarily affects the bile ducts inside and outside the liver) or choledocholithiasis (gallstones in the bile ducts).

11. How Long Is the Treatment Duration for Cholangitis?

The treatment duration for cholangitis can vary depending on several factors, including the severity of the infection, the underlying cause, and the response to treatment. In general, cholangitis requires an initial period of intravenous (IV) antibiotic therapy followed by oral antibiotics to complete the course of treatment. The course of treatment could last from a few days to a few weeks.

12. What Is the WBC Count in Cholangitis?

In cholangitis, the white blood cell (WBC) count is often elevated. White blood cells are an essential part of the immune system and are in charge of protecting the body from inflammation and infection. An increase in the WBC count is a common response to an infection or inflammation in the body, including cholangitis.

13. Could A CT Scan Detect Cholangitis?

Yes, a CT (computed tomography) scan can be useful in detecting and evaluating cholangitis. A CT scan gives precise cross-sectional images of the abdomen, including the liver, bile ducts, and surrounding organs. It can help identify signs of inflammation, obstruction, or other abnormalities associated with cholangitis

14. What Complications Can Arise From Cholangitis?

When the infection in the bile ducts travels to the bloodstream, it can cause sepsis or septicemia (widespread inflammation throughout the body), which are both serious conditions. Sepsis is a serious and life-threatening condition that occurs when the body's response to infection causes widespread inflammation and organ dysfunction. Other complications are liver abscess (collection of pus within the liver), biliary stricture (narrowing or constriction of the bile ducts), biliary cirrhosis (progressive inflammation and destruction of the small bile ducts), and organ failure.

15. What Is the Life Expectancy With Cholangitis?

The life expectancy for an individual with cholangitis can vary according to various factors, including the underlying cause of cholangitis, the severity of the infection, the presence of complications, and the effectiveness of treatment. Without proper treatment, cholangitis can lead to severe complications such as sepsis, abscess formation, liver failure, or organ dysfunction, which can significantly impact life expectancy.

Sources

Dr. Jagdish Singh

Medical Gastroenterology

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