Ascending Cholangitis

A 47-year-old female presents to her GP with intense pain in the right upper quadrant (RUQ). She has a history of gallstones. Physical exam shows that she is febrile, has scleral jaundice, and has a BMI of 38. What is your likely diagnosis?

So, what is acute cholangitis? Acute cholangitis is a bacterial infection of the biliary tract. It is commonly known as ascending cholangitis as the organisms responsible for this pathology often ascend from the duodenum. Bugs that cause this are mostly gram-negative bacteria such as E. coli, Klebsiella, and Enterococcus. In terms of pathophysiology, it is important to first have an understanding that secretions from the gallbladder and pancreas clear out any organisms attempting to ascend the biliary tree. However, this pathology commences through biliary tree obstruction, commonly through choledocholithiasis (which is obstruction of the common bile duct) or a biliary stricture. This obstruction results in bile stasis, allowing pathogens to ascend. As secretions from the pancreas and gallbladder continue, intraductal pressure increases, spreading the bacteria systemically.

Ok, so now that we have a hold on the pathophysiology, the risk factors for this pathology make a lot of sense. As choledocholithiasis is mostly responsible for acute cholangitis, risk factors for acute cholangitis are the 6Fs of gallstone formation. These include being Female (as estrogen increases cholesterol-rich bile, and progesterone is a muscle relaxant decreasing gallbladder contraction and encouraging stasis), Fertile, Fat, Forty, Fair-skinned, and a FHx of gallstones.

The symptoms of acute cholangitis are also super easy to remember too. They can be remembered by Reynolds' pentad. The 5 features of this pentad are RUQ pain, fever, jaundice, hypotension (through septic shock), and confusion.

Before we talk about diagnosing this condition, it is first important to talk about an ERCP. This stands for endoscopic retrograde cholangiopancreatography and is essentially an imaging procedure by which an endoscope is used to inject contrast into the bile ducts so blockages to the biliary tree can be viewed on an X-ray. So, to make a definitive diagnosis of this condition, there must be at least one sign of inflammation such as fever, chills, or raised WBCs, one sign of cholestasis such as jaundice or deranged liver function tests, and one characteristic imaging finding. A characteristic finding involves biliary dilation greater than 7mm, or a sign of underlying etiology such as choledocholithiasis or biliary stricture.

In terms of treatment, the patient should first be stabilized and administered with empiric antibiotic therapy. This includes gentamicin and amoxicillin. Biliary drainage should be undertaken through ERCP within the first 24-48 hours, and the underlying cause should be treated, such as ERCP extraction of gallstone in choledocholithiasis.