Cholangitis: Bile Duct Infection – Emergency Signs & Treatment

What is cholangitis? (Ascending cholangitis)

Ascending cholangitis, often simply called cholangitis, is a serious bacterial infection of the bile duct. It occurs when the bile duct is obstructed (usually by a stone) and bacteria from the intestine ascend into the biliary tree. The infection can rapidly progress to sepsis, septic shock, and death if not treated urgently. Cholangitis is a medical emergency requiring immediate hospitalisation, intravenous antibiotics, and drainage of the bile duct (usually by ERCP).

Causes – bile duct obstruction (stones, strictures, tumours)

Cholangitis is almost always secondary to bile duct obstruction. Common causes include:

• Choledocholithiasis (common bile duct stones): The most common cause (60‑80%). Stones block the bile duct, allowing bacteria to proliferate.
• Biliary strictures (benign or malignant): Post‑operative strictures, primary sclerosing cholangitis, or pancreatic cancer.
• Biliary stents: Long‑term stents can become colonised with bacteria.
• Parasitic infections: Clonorchis sinensis, Ascaris lumbricoides (in endemic regions).
• ERCP complications: Post‑ERCP cholangitis (rare).

The most common infecting organisms are enteric Gram‑negative bacilli (E. coli, Klebsiella, Enterobacter) and enterococci. Polymicrobial infection is common.

Symptoms – Charcot’s triad and Reynolds’ pentad

The classic presentation of acute cholangitis is Charcot’s triad, present in 50‑70% of patients:

• Fever (often with rigors): Temperature >38.5°C (101°F).
• Jaundice: Yellow skin/eyes, dark urine, pale stools.
• Right upper quadrant (RUQ) pain: May be mild or severe.

Reynolds’ pentad adds two more features, indicating severe sepsis:

• Hypotension (low blood pressure).
• Altered mental status (confusion, lethargy).

Other symptoms: nausea, vomiting, pruritus (itching), and abdominal tenderness.

Diagnosis – blood tests, imaging (CT, MRCP, ERCP)

Diagnosis is based on clinical presentation plus laboratory and imaging findings:

• Blood tests: Elevated white blood cell count (leucocytosis), elevated C‑reactive protein (CRP), elevated bilirubin (direct), alkaline phosphatase (ALP), and GGT. Blood cultures are positive in 30‑50% of cases.
• Abdominal ultrasound: May show bile duct dilation (>6‑8mm) and sometimes stones or masses.
• CT scan: Shows bile duct dilation, pericholecystic changes, and can identify the cause (stone, mass, stricture).
• MRCP (magnetic resonance cholangiopancreatography): Non‑invasive, excellent for visualising bile duct stones and strictures.
• ERCP (endoscopic retrograde cholangiopancreatography): Both diagnostic and therapeutic. Performed urgently after stabilisation.

Emergency treatment – antibiotics, ERCP drainage

Cholangitis is a medical emergency. Treatment follows a stepwise approach:

1. Immediate hospitalisation (ICU if haemodynamically unstable).
2. Intravenous fluids and vasopressors for hypotension.
3. Broad‑spectrum antibiotics: Cover Gram‑negative rods, enterococci, and anaerobes. Common regimens:
   • Piperacillin‑tazobactam (Zosyn).
   • Meropenem or imipenem for severe sepsis.
   • Ceftriaxone + metronidazole (mild cases).
   • Ciprofloxacin + metronidazole (in penicillin‑allergic).
4. Emergency biliary drainage – the key to survival:
   • ERCP with sphincterotomy and stone extraction: First‑line if available. Success rate >90%.
   • If ERCP fails or is unavailable: Percutaneous transhepatic biliary drainage (PTBD) or endoscopic ultrasound‑guided biliary drainage (EUS‑BD).
   • Temporary biliary stenting: If stone cannot be removed immediately, a stent is placed to decompress the bile duct.
5. Follow‑up: After infection resolves, treat the underlying cause (e.g., cholecystectomy for gallstones, stricture repair).

Complications – sepsis, liver abscess, death

If not treated promptly, cholangitis can lead to:

• Septic shock and multi‑organ failure (MOF).
• Liver abscess: Pus collection within the liver.
• Secondary biliary cirrhosis (chronic, recurrent cholangitis).
• Portal vein thrombosis (pylephlebitis).
• Death: Mortality remains 2‑5% with modern treatment, but up to 30‑50% in patients with Reynolds’ pentad.

Prevention – treating underlying bile duct obstruction

After an episode of cholangitis, the underlying cause must be addressed to prevent recurrence:

• If caused by gallstones: Cholecystectomy (if the gallbladder is intact) and ERCP with stone extraction.
• If caused by a stricture: Balloon dilation, stenting, or surgical repair.
• If caused by a tumour: Surgical resection or palliative stenting.
• For patients with recurrent cholangitis due to primary sclerosing cholangitis: Ursodeoxycholic acid (UDCA) and endoscopic therapy.

Interactive FAQ – Cholangitis

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Disclaimer: This information is for educational purposes. If you have fever, jaundice, and abdominal pain, seek emergency medical care immediately at Vivekananda Hospital.