Ascending cholangitis: Difference between revisions

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{{good article}}

{{Infobox medical condition (new)

| name = Ascending cholangitis

| synonyms = acute cholangitis, cholangitis

| image = Cholangitis.jpg

| caption = Duodenoscopy image of pus extruding from the [[Ampullaampulla of Vater]], indicative of cholangitis

| pronounce =

| field = [[Gastroenterology]] <br> [[General surgery]]

| symptoms = [[jaundice]], [[fever]] and [[abdominal pain]]

| complications =

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Bile duct obstruction, which is usually present in acute cholangitis, is generally due to [[gallstone]]s. 10–30% of cases, however, are due to other causes such as [[benign]] stricturing (narrowing of the bile duct without an underlying tumor), postoperative damage or an altered structure of the bile ducts such as narrowing at the site of an [[anastomosis]] (surgical connection), various tumors ([[cholangiocarcinoma|cancer of the bile duct]], [[gallbladder cancer]], cancer of the [[ampulla of Vater]], [[pancreatic cancer]], [[small intestine cancer|cancer of the duodenum]]), [[anaerobic organism]]s such as [[Clostridium]] and [[Bacteroides]] (especially in the elderly and those who have undergone previous surgery of the [[biliary system]]).<ref name=Kinney/>

Parasites which may infect the liver and bile ducts may cause cholangitis; these include the [[roundworm]] ''[[Ascaris lumbricoides]]'' and the [[liver flukes]] ''[[Clonorchis sinensis]]'', ''[[Opisthorchis viverrini]]'' and ''[[Opisthorchis felineus]]''.<ref>{{cite journal |author=Lim JH |title=Liver flukes: the malady neglected |journal=Korean J Radiol |volume=12 |issue=3 |pages=269–79 |year=2011 |pmid=21603286 |pmc=3088844 |doi=10.3348/kjr.2011.12.3.269 }}</ref> In people with [[AIDS]], a large number of opportunistic organisms has been known to cause ''AIDS cholangiopathy'', but the risk has rapidly diminished since the introduction of [[Antiretroviral drug|effective AIDS treatment]].<ref name=Kinney/><ref name=Kimura2007>{{cite journal |vauthors=Kimura Y, Takada T, Kawarada Y | title=Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines | journal=J Hepatobiliary Pancreat Surg | year=2007 | volume=14 | issue=1 | pages=15–26 | pmid=17252293 | doi=10.1007/s00534-006-1152-y | pmc=2784509|display-authors=etal}}</ref> Cholangitis may also complicate medical procedures involving the bile duct, especially ERCP. To prevent this, it is recommended that those undergoing ERCP for any indication receive prophylactic (preventative) antibiotics.<ref name=Williams/><ref>{{cite journal|last1=Brand|first1=M|last2=Bizos|first2=D|last3=O'Farrell P|first3=Jr|title=Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography.|journal=The Cochrane Database of Systematic Reviews|date=6 October 2010|issue=10|pages=CD007345|doi=10.1002/14651858.CD007345.pub2|pmid=20927758|pmc=12305484}}</ref>

The presence of a permanent biliary stent (e.g. in pancreatic cancer) slightly increases the risk of cholangitis, but stents of this type are often needed to keep the bile duct patent under outside pressure.<ref name=Kinney/>

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The [[gold standard (test)|gold standard]] test for biliary obstruction is still [[endoscopic retrograde cholangiopancreatography]] (ERCP). This involves the use of [[endoscopy]] (passing a tube through the mouth into the [[esophagus]], [[stomach]] and thence to the [[duodenum]]) to pass a small cannula into the bile duct. At that point, [[radiocontrast]] is injected to opacify the duct, and [[X-ray]]s are taken to get a visual impression of the biliary system. On the endoscopic image of the ampulla, one can sometimes see a protuberant ampulla from an impacted gallstone in the common bile duct or the frank extrusion of pus from the common bile duct orifice. On the X-ray images (known as [[Cholangiography|cholangiograms]]), gallstones are visible as non-opacified areas in the contour of the duct. For diagnostic purposes, ERCP has now generally been replaced by MRCP. ERCP is only used first-line in critically ill patients in whom delay for diagnostic tests is not acceptable; however, if the index of suspicion for cholangitis is high, an ERCP is typically done to achieve drainage of the obstructed common bile duct.<ref name=Kinney/>

If other causes rather than gallstones are suspected (such as a [[tumor]]), [[computed tomography]] and [[endoscopic ultrasound]] (EUS) may be performed to identify the nature of the obstruction. EUS may be used to obtain [[biopsy]] (tissue sample) of suspicious masses.<ref name=Kinney/> EUS may also replace diagnostic ERCP for stone disease, although this depends on local availability.<ref name=Williams>{{cite journal |vauthors=Williams EJ, Green J, Beckingham I, Parks R, Martin D, Lombard M | title=Guidelines on the management of common bile duct stones | journal=Gut | year=2008 | volume=57 | pages=1004–1021 | pmid=18321943 | doi=10.1136/gut.2007.121657 | url=http://gut.bmj.com/cgi/content/full/57/7/1004 | issue=7| s2cid=206945855 | url-access=subscription }}</ref>

==Treatment==

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=== Cholecystectomy ===

Not all gallstones implicated in ascending cholangitis actually originate from the gallbladder, but [[cholecystectomy]] (surgical removal of the gallbladder) is generally recommended in people who have been treated for cholangitis due to gallstone disease. This is typically delayed until all symptoms have resolved and ERCP or MRCP have confirmed that the bile duct is clear of gallstones.<ref name=Kinney/><ref name=schwartz/><ref name=Williams/> Those who do not undergo cholecystectomy have an increased risk of recurrent biliary pain, jaundice, further episodes of cholangitis, and need for further ERCP or cholecystostomy; the risk of death is also significantly increased.<ref>{{cite journal |vauthors=McAlister VC, Davenport E, Renouf E |title=Cholecystectomy deferral in patients with endoscopic sphincterotomy |journal=Cochrane Database Syst Rev |issue=4 |pages=CD006233 |year=2007 |volume=2010 |pmid=17943900 |doi=10.1002/14651858.CD006233.pub2 |pmc=8923260 |editor1-last=McAlister |editor1-first=Vivian }}</ref>

== Biliary sepsis ==

[[Biliary sepsis]] is a systemic complication of acute cholangitis that occurs when infection spreads from the bile ducts into the bloodstream.

A systemic infection resulting from [[Intestinal permeability|bacterial translocation]] from the [[biliary tract]], most commonly due to acute [[Primary sclerosing cholangitis|cholangitis]] or [[suppurative cholecystiti]]s. It is a life-threatening complication of biliary obstruction (e.g., [[Common bile duct stone|choledocholithiasis]], strictures) and requires urgent intervention.<ref>{{Cite journal |last=Kiriyama |first=Seiki |last2=Kozaka |first2=Kazuto |last3=Takada |first3=Tadahiro |last4=Strasberg |first4=Steven M. |last5=Pitt |first5=Henry A. |last6=Gabata |first6=Toshifumi |last7=Hata |first7=Jiro |last8=Liau |first8=Kui-Hin |last9=Miura |first9=Fumihiko |last10=Horiguchi |first10=Akihiko |last11=Liu |first11=Keng-Hao |last12=Su |first12=Cheng-Hsi |last13=Wada |first13=Keita |last14=Jagannath |first14=Palepu |last15=Itoi |first15=Takao |date=2018 |title=Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos) |url=https://onlinelibrary.wiley.com/doi/abs/10.1002/jhbp.512 |journal=Journal of Hepato-Biliary-Pancreatic Sciences |language=en |volume=25 |issue=1 |pages=17–30 |doi=10.1002/jhbp.512 |issn=1868-6982|url-access=subscription }}</ref>

==Prognosis==