Cholangitis

6 Interesting Facts of Cholangitis 

1. Acute (ascending) cholangitis is a systemic condition characterized by inflammation and infection in the bile duct caused by bacteria ascending from the duodenum in the presence of common bile duct obstruction 
2. Most common cause is obstruction by gallstones, but may also be precipitated by benign or malignant stenoses, obstructed biliary stents, external compression, and parasitic colonization of the bile duct 
3. Classic presentation is right upper quadrant pain and tenderness on palpation, jaundice, and fever and/or shaking chills (Charcot triad); additional signs and symptoms associated with sepsis may also be present 
4. Diagnosis is based on history, clinical and laboratory evidence of systemic inflammation and cholestasis, and diagnostic imaging results showing biliary dilatation or a likely cause of obstruction
5. Management of all patients includes empiric antimicrobial therapy, analgesia, IV fluids, and biliary drainage via endoscopic retrograde cholangiopancreatography in most cases
6. Empiric antibiotic regimen is based on severity of cholangitis, likely pathogens involved, renal and hepatic function, and risk factors for antimicrobial resistance

Pitfalls

• Consider acute cholangitis in elderly patients with fever and hypotension, even in the absence of classic signs and symptoms 

• Acute (ascending) cholangitis is a systemic condition characterized by inflammation and infection in the bile duct caused by bacteria ascending from the duodenum in the presence of common bile duct obstruction 
  • Most common cause is obstruction by gallstones but may also be precipitated by benign or malignant stenoses, obstructed biliary stents, external compression, or parasitic colonization of the bile duct 

Classification

• Classified according to the following severity grades:
  • Mild (grade I)
    • Defined as acute cholangitis that does not meet criteria for grade II or III cholangitis at initial diagnosis
  • Moderate (grade II)
    • Defined as acute cholangitis that is associated with any 2 of the following:
      • Abnormal WBC count (over 12,000 mm³ or under 4000 mm³) 
      • High fever (39 °C or above) 
      • Age 75 years or older 
      • Hyperbilirubinemia (5 mg/dL or more) 
      • Hypoalbuminemia
    • At risk of progressing to grade III unless there is immediate intervention
  • Severe (grade III)
    • Defined as acute cholangitis accompanied by dysfunction in 1 or more systems/organs
    • May be associated with renal failure, hypotension, hepatic dysfunction, thrombocytopenia, altered level of consciousness, or respiratory failure

Diagnosis

Clinical Presentation

Wide spectrum of clinical presentation ranging from mild, intermittent pain to life-threatening septic shock

History

• Intermittent fever and/or shaking chills 
• Right upper quadrant or upper abdominal pain 
• Jaundice
• In advanced cases, symptoms may progress to include those associated with hypotension and altered mental status 
• May have history of gallstones, previous biliary procedures, or a biliary stent in situ 
• In patients aged 80 years or older, cholangitis can present without abdominal pain, fever, or jaundice; may present with only malaise, symptoms of hypotension, or altered consciousness 

Physical examination

• Classic Charcot triad is observed in approximately 50% to 70% of patients and includes the following: 
  • Right upper quadrant pain and tenderness on palpation
  • Jaundice
  • Fever and/or shaking chills
• Evidence of sepsis in patients with severe disease (presence of hypotension and altered mental status in addition to those of Charcot triad is known as Reynolds pentad and is observed in less than 30% of cases): 
  • Altered level of consciousness
  • Hypotension
  • Pallor
  • Tachycardia
  • Tachypnea
• Patients aged 80 years or older are more likely to present with features of Reynolds pentad or unexplained malaise, and are less likely to have components of Charcot triad compared to younger patients 

Causes

• Acute cholangitis is caused by bacterial growth in bile in the presence of biliary obstruction and stasis 
  • Most common organisms involved are Escherichia coli (25%-50% of cases), Klebsiella pneumoniae (15%-20% of cases), Enterococcus species (10%-20% of cases), and Enterobacter species (5%-10% of cases) 
  • Enterococcus species (10%-20% of cases) are the most commonly detected bacteria in patients with biliary stents 
• Most common cause of obstruction is choledocholithiasis (gallstones in the common bile duct) 
• Other causes include the following:
  • Malignant stenoses (ie, tumors of the bile duct, gallbladder, ampulla, duodenum, pancreas) account for between 10% and 30% of cases 
  • Benign biliary strictures (eg, primary sclerosing cholangitis)
  • Congenital stenoses
  • Postoperative complications (eg, damage to bile duct, choledochojejunostomy stricture)
  • Inflammatory conditions
  • Pancreatitis
  • Parasitic colonization of bile duct
  • External pressure
  • Fibrosis of papilla
  • Duodenal diverticulum
  • Blood clot
  • Sump syndrome after biliary-enteric anastomosis
  • Iatrogenic introduction of bacteria into biliary tract (most commonly during endoscopic retrograde cholangiopancreatography for biliary obstruction) 

Risk factors and/or associations

Other risk factors/associations

• AIDS cholangiopathy 
• Risk factors for cholelithiasis also increase the risk of developing cholangitis 
  • Obesity
  • High-fat diet
  • Sedentary lifestyle
  • Rapid weight loss
  • Pregnancy 
  • Drugs that promote gallstone formation
    • Ceftriaxone
    • Octreotide
    • Anticholinergic agents
    • Dapsone
    • Erythromycin
    • Ampicillin
    • Fibrates
    • Hormone replacement therapy

Diagnostic Procedures

Primary diagnostic tools

• Diagnose based on history, clinical and laboratory evidence of systemic inflammation and cholestasis, and diagnostic imaging findings suggesting likely cause
  • Charcot triad of fever, right upper quadrant pain, and jaundice is pathognomonic for cholangitis and has a specificity of 85%; however, its sensitivity is much lower, approximately 25% in recent studies 
    • In patients aged 80 years or older, cholangitis may present with only malaise, symptoms of hypotension, or altered consciousness 
  • Obtain results of CBC, C-reactive protein, blood cultures, and hepatic function tests in all patients to help establish diagnosis and direct management 
    • Electrolyte, BUN, creatinine, and albumin levels, and prothrombin time are also indicated to provide information about the severity of illness 
  • Obtain initial abdominal ultrasonogram, CT of abdomen with contrast, or magnetic resonance cholangiopancreatogram to confirm presence of gallstone, tumor, or stent inducing bile duct obstruction 
    • Before therapeutic intervention, endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography (less common) is indicated to confirm anatomic site and nature of obstruction; allows biopsy of any lesion identified and simultaneous therapeutic intervention (ie, biliary drainage, stone extraction, stent placement) 
      • Obtain cultures from bile or biliary stent (if present) during endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography
  • Diagnostic criteria have been developed based on clinical, laboratory, and radiologic findings 
    • Criteria
      • A: Systemic inflammation
        • Fever/chills
        • Laboratory findings (abnormal WBC count over 10,000 mm³ or under 4000 mm³, elevated C-reactive protein level 1 mg/dL or higher)
      • B: Cholestasis
        • Jaundice (bilirubin level 2 mg/dL or greater)
        • Abnormal hepatic function test results (elevated levels of bilirubin, alkaline phosphatase, AST, ALT, and γ-glutamyl transpeptidase over 1.5 upper limit of normal)
      • C: Imaging findings
        • Biliary dilatation
        • Evidence of underlying cause (eg, stricture, gallstone)
    • Suspect cholangitis if 1 item in A and 1 item in either B or C categories are present
    • Definite diagnosis can be made if 1 item in each of the A, B, and C criteria categories are present

Laboratory

• CBC panel
  • WBC count more than 10,000/mm³ or less than 4000/mm³ supports diagnosis 
  • Presence of thrombocytopenia indicates severe illness
• C-reactive protein test
  • C-reactive protein level of 1 mm/dL or greater supports diagnosis 
• Blood cultures
  • Obtain for all patients to help direct antimicrobial therapy
• Hepatic function panel
  • The following findings are suggestive of acute cholangitis:
    • Serum ALT level elevated more than 1.5 times upper limit of normal 
    • Serum AST level elevated more than 1.5 times upper limit of normal 
    • Serum γ-glutamyl transpeptidase level elevated more than 1.5 times upper limit of normal 
    • Serum alkaline phosphatase level elevated more than 1.5 times upper limit of normal 
    • Bilirubin level elevated 2 mg/dL or higher 
• Biliary cultures
  • Cultures of bile, common bile duct stones, or blocked biliary stent removed during endoscopic retrograde cholangiopancreatography result in positive findings in over 90% of cases

Imaging

• Abdominal ultrasonography
  • First line imaging test in all patients with suspected acute cholangitis 
  • Can determine presence and cause of obstruction and degree of biliary dilatation
• CT of abdomen with contrast
  • Complements ultrasonography
  • Can determine presence and cause of obstruction and degree of biliary dilatation
  • Can depict all abdominal organs and identify complications of acute cholangitis 
• Magnetic resonance cholangiopancreatography
  • Recommended for etiologic diagnosis due to high sensitivity at detecting biliary stones and malignant obstruction 
  • Noninvasive; however, if common bile duct stones are visualized, additional therapeutic procedure will be required 
• Endoscopic ultrasonography
  • Comparable accuracy to magnetic resonance cholangiopancreatography at diagnosing common bile duct stones; however, less accurate for malignancy
  • Minimally invasive; avoids risks associated with endoscopic retrograde cholangiopancreatography
    • However, endoscopic retrograde cholangiopancreatography may be performed during the same anesthetic procedure if therapeutic intervention is indicated 

Procedures

• Technique for visualizing biliary and pancreatic ducts and gallbladder; also allowing simultaneous therapeutic intervention (eg, biliary drainage, stone extraction, placement of stent)
• Involves passage of an endoscope into the duodenum thereby allowing catheterization of the major duodenal papilla and injection of radiologic contrast medium into the bile and pancreatic ducts
• Confirm anatomic site and nature of obstruction before any therapeutic intervention for acute cholangitis
• Bowel perforation
• Unstable patient
• Anatomic abnormalities of gastrointestinal tract
• Altered gastrointestinal anatomy due to surgery
• Untreated coagulopathy
• Acute pancreatitis
• Endoscope-associated infection
• Bowel perforation
• Gold standard for diagnosing common bile duct stones; allows simultaneous biliary culture and drainage, stone extraction, or stent placement in acute cholangitis 

Differential Diagnosis

Most common

• Acute cholecystitis 
  • Acute inflammation of the gallbladder; most commonly resulting from obstruction of cystic duct by an impacted gallstone
  • Presents with severe right upper quadrant pain like that of acute cholangitis; may also have fever
  • Unlike acute cholangitis, may have nausea and vomiting, palpable right upper quadrant mass, and positive Murphy sign, but rarely jaundice
  • Diagnosis is confirmed based on history, presence of clinical and laboratory evidence of local inflammation with or without systemic inflammation, and characteristic ultrasonography or cholescintigraphy findings
• Biliary colic (cholelithiasis)
  • Biliary colic describes pain related to the transient obstruction of the cystic duct by a gallstone
  • Presents with severe right upper quadrant pain like that of acute cholangitis
  • Unlike that of cholangitis, pain resolves after several hours and is not associated with fever, chills, or jaundice; may be postprandial or nocturnal
  • Diagnosis is based on history, absence of signs of systemic inflammation or cholestasis on physical examination, results of laboratory testing, and presence of gallstones but no evidence of biliary duct dilatation on ultrasonography
• Choledocholithiasis 
  • Describes presence of gallstones in the common bile duct, which can cause biliary obstruction
  • May present with right upper quadrant abdominal pain and jaundice like that of acute cholangitis
  • Unlike cholangitis, pain may resolve and is not associated with fever or chills
  • Diagnosis is confirmed based on history, absence of clinical and laboratory evidence of systemic inflammation, and characteristic ultrasonography, CT, or magnetic resonance cholangiopancreatography findings
• Acute pancreatitis 
  • Acute inflammation of the pancreas
  • Similar to acute cholangitis, pancreatitis may present with persistent, severe upper abdominal pain with fever and jaundice
  • Unlike acute cholangitis, pain associated with pancreatitis is exacerbated by supine positioning and tends to radiate to the back
    • In severe cases, bruising in the periumbilical (Cullen sign) or flank (Grey Turner sign) may be present
  • Diagnosis is based on history, physical examination, elevated amylase level with or without bilirubin on laboratory testing, and pancreatic inflammation on CT

Treatment Goals

• Eradication of bacterial infection with antibiotic therapy, with or without biliary drainage
• Aggressive supportive management of sepsis-related organ dysfunction 
• Removal of gallstones or other causes of biliary obstruction

Disposition

Admission criteria

Admit patients with acute cholangitis 

Criteria for ICU admission

• Admit patients with severe acute cholangitis to intensive care; may require ventilatory and circulatory support 

Recommendations for specialist referral

• Refer to gastroenterologist or general or hepatobiliary surgeon

Treatment Options

Initiate empiric IV antibiotic therapy in all patients 

• Select antibiotic regimen based on likely pathogens involved, renal and hepatic function, and risk factors for antimicrobial resistance
• Use 1 of the following agents in mild (grade I), community-acquired acute cholangitis; anaerobic coverage with metronidazole is also warranted if biliary-enteric anastomosis is present: 
  • Cephalosporins (eg, cefazolin, cefotaxime, ceftriaxone, cefuroxime)
  • Carbapenems (eg, ertapenem)
  • Fluoroquinolones (eg, ciprofloxacin, levofloxacin, moxifloxacin)
• Use 1 of the following options in moderate (grade II) community-acquired acute cholangitis; anaerobic coverage with metronidazole is also warranted if biliary-enteric anastomosis is present: 
  • Penicillins (eg, piperacillin-tazobactam)
  • Cephalosporins (eg, cefepime, cefotaxime, ceftazidime, ceftriaxone, cefuroxime)
  • Carbapenems (eg, ertapenem)
  • Fluoroquinolones (eg, ciprofloxacin, levofloxacin, moxifloxacin)
• Treat severe (grade III) or health care–associated acute cholangitis with vancomycin plus 1 of the following agents: vancomycin is also recommended for coverage of Enterococcus; anaerobic coverage with metronidazole is also warranted if biliary-enteric anastomosis is present: 
  • Penicillins (eg, piperacillin-tazobactam)
  • Cephalosporins (eg, cefepime, ceftazidime)
  • Carbapenem (eg, doripenem, ertapenem, imipenem-cilastatin, meropenem)
  • Monobactam (eg, aztreonam)
  • Vancomycin is also recommended for coverage of Enterococcus
• Add an antifungal agent in patients with biliary stents or hospital-acquired infection 
• Modify initial regimen according to results of blood or biliary cultures if necessary 
• When patient is able to tolerate oral intake, consider converting to oral antibiotic therapy guided by susceptibility patterns of any organisms identified; options include any of the following with or without metronidazole: 
  • Penicillins (eg, amoxicillin-clavulanate)
  • Cephalosporins (eg, cephalexin)
  • Fluoroquinolones (eg, ciprofloxacin, levofloxacin, moxifloxacin)
• Continue antibiotic therapy for 4 to 7 days after source of infection is controlled; if residual stones or obstruction are present, continue treatment until resolved 
  • Continue antimicrobial therapy for at least 2 weeks if bacteremia with gram-positive cocci is present

Provide supportive medical care with analgesia, IV fluids, monitoring of vital signs, and nothing by mouth 

• Patients with severe (grade III) cholangitis require urgent stabilization and management of organ dysfunction; may include ventilatory support and use of vasopressors

Arrange biliary drainage for all but the mildest cases of acute cholangitis 

• Methods include surgical, percutaneous transhepatic, and endoscopic drainage
  • Endoscopic transpapillary drainage during endoscopic retrograde cholangiopancreatography is the method of choice, being minimally invasive, safer, and with higher rates of success for relief of bile duct obstruction than percutaneous biliary drainage 
    • 2 main approaches—endoscopic nasobiliary drainage with external drainage and endoscopic biliary stenting—have similar outcomes; choice depends on surgeon’s preference
      • Newer techniques include balloon enteroscope–assisted bile duct drainage and endoscopic ultrasonography–guided bile duct drainage 
    • Endoscopic sphincterotomy also may be obtained to remove bile duct stone in a single session in patients without severe cholangitis 
  • Percutaneous drainage (percutaneous transhepatic biliary drainage) is an alternative if endoscopic drainage is anatomically difficult or unavailable 
    • Associated with increased risks and requires longer hospitalization; performed less frequently
  • Surgical drainage by means of hepaticojejunostomy or T-tube placement is rarely indicated, as a last resort; may have role in patients with acute cholangitis due to unresectable malignancies (eg, cancer of pancreatic head) 
  • Percutaneous cholecystostomy, an intervention for acute cholecystitis, may also be an option for acute cholangitis in high-risk elderly patients or critically ill patients 
• Timing depends on severity of disease and surgical risk
  • Mild (grade I) cholangitis
    • Biliary drainage is not required for most cases; may be tried if initial medical treatment is not effective
    • Drainage and definitive procedure to address cause of cholangitis can be performed electively; there is no benefit to early drainage 
  • Moderate (grade II) cholangitis
    • Early biliary drainage is indicated (defined as within 24-72 hours) 
      • Tokyo guidelines defined urgent and early drainage as within 24 or 48 hours, respectively; US guidelines recommend drainage within 48 hours and European ones recommend drainage within 48 to 72 hours 
      • Endoscopic retrograde cholangiopancreatography drainage within 48 hours of symptom onset is associated with reduced rates of in-hospital mortality, 30-day mortality, and organ failure, and shorter duration of hospitalization 
        • In patients with moderate-to-severe cholangitis secondary to malignant biliary obstruction, endoscopic retrograde cholangiopancreatography within 48 hours was associated with lower 30-day and 180-day mortality rates; lowest rates were observed in a group that underwent drainage within 24 hours 
    • Definitive procedure to address cause of acute cholangitis is indicated after general condition has improved
  • Severe (grade III) cholangitis
    • Obtain urgent biliary drainage as soon as patient has been stabilized (within 12-24 hours) 
    • Definitive treatment of underlying condition is indicated after acute illness has resolved

Arrange definitive treatment of underlying cause of biliary obstruction after resolution of acute cholangitis 

• Treatment usually consists of elective laparoscopic cholecystectomy that is optimally done within 6 weeks after endoscopic clearance of gallstones that caused the acute episode 

Drug therapy

• Antibiotics
  • Penicillin and β-lactamase inhibitors
    • Piperacillin-tazobactam
      • Piperacillin Sodium, Tazobactam Sodium Solution for injection; Adults: 3.375 g (3 g piperacillin and 0.375 g tazobactam) IV every 4 to 6 hours or 4.5 g (4 g piperacillin and 0.5 g tazobactam) IV every 6 hours for 3 to 7 days.
    • Amoxicillin-clavulanic acid
      • For oral de-escalation therapy
      • Amoxicillin Trihydrate, Clavulanate Potassium Oral tablet; Adults: 875 mg amoxicillin with 125 mg clavulanate PO every 12 hours or 500 mg amoxicillin with 125 mg clavulanate PO every 8 hours for a total treatment duration of 3 to 7 days.
  • Cephalosporins
    • Cefoxitin
      • Cefoxitin Sodium Solution for injection; Adults: 1 to 2 g IV every 6 hours for 3 to 7 days.
    • Cefazolin (use in combination with metronidazole)
      • Cefazolin Sodium Solution for injection; Adults: 1 g IV or IM every 6 to 8 hours (Max: 6 g/day).
    • Ceftriaxone (use in combination with metronidazole)
      • Ceftriaxone Sodium Solution for injection; Adults: 1 to 2 g IV/IM every 12 to 24 hours for 3 to 7 days.
    • Ceftazidime (use in combination with metronidazole)
      • Ceftazidime Sodium Solution for injection; Adults: 1 to 2 g IV every 8 hours for 3 to 7 days.
    • Cefepime (use in combination with metronidazole)
      • Cefepime Hydrochloride Solution for injection; Adults: 1 to 2 g IV every 8 to 12 hours for 3 to 7 days.
    • Cephalexin
      • For oral de-escalation therapy
      • Cephalexin Hydrochloride Oral tablet; Adults: 250 mg PO every 6 hours or 500 mg PO every 12 hours. Severe infections may require higher doses (eg, 0.5 to 1 g PO every 6 hours). Max: 4 g/day.
  • Fluoroquinolones
    • NOTE: Systemic fluoroquinolones have been associated with disabling and potentially irreversible serious adverse effects involving the central nervous system, nerves, tendons, muscles, and joints. Fluoroquinolones should be reserved for serious bacterial infections where benefit outweighs the potential risk of serious adverse effects 
    • Ciprofloxacin (use in combination with metronidazole)
      • Ciprofloxacin Solution for injection; Adults: 400 mg IV every 8 hours for 3 to 7 days.
    • Moxifloxacin
      • Moxifloxacin Hydrochloride Solution for injection; Adults: 400 mg IV every 24 hours for 3 to 7 days.
      • Moxifloxacin Hydrochloride Oral tablet; Adults: 400 mg PO every 24 hours for 3 to 7 days.
  • Carbapenems
    • Ertapenem
      • Ertapenem Solution for injection; Adults: 1 g IV once daily for 3 to 7 days.
  • Nitroimidazole
    • Metronidazole
      • Metronidazole Solution for injection; Adults: 1 g IV loading dose then 500 mg IV every 6 to 12 hours or 1.5 g IV every 24 hours for 3 to 7 days.
  • Glycopeptide
    • Vancomycin
      • Therapy should be guided by serum vancomycin concentrations/area under curve
      • Vancomycin Hydrochloride Solution for injection; Adults: 25 to 30 mg/kg (actual body weight) IV loading dose, then 15 to 20 mg/kg/dose (actual body weight) IV every 8 to 12 hours per guidelines. Adjust dose based on serum concentrations. FDA-approved dosage is 500 mg IV every 6 hours or 1 g IV every 12 hours. For MRSA, treat at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia.
  • Monobactam
    • Aztreonam
      • Aztreonam Solution for injection; Adults: 1 to 2 g IV every 6 to 8 hours for 3 to 7 days.

Nondrug and supportive care

Procedures

Endoscopic biliary drainage 

General explanation

• Procedure to drain an obstructed bile duct system; may also allow definitive management of cause of obstruction
• Carried out during endoscopic retrograde cholangiopancreatography, which involves passage of an endoscope into the duodenum, catheterization of major duodenal papilla, and injection of radiologic contrast medium into the bile and pancreatic ducts 
• Biliary decompression is achieved by stent placement or nasobiliary drainage 
  • Newer techniques include balloon enteroscope–assisted bile duct drainage and endoscopic ultrasonography–guided bile duct drainage 
• Endoscopic sphincterotomy, in which bile duct is cannulated via a sphincterotome and papillary sphincter is cut, may also be performed in order to extract common bile duct stones, treat stenoses, or place stent 

Indication

• Treatment of acute cholangitis caused by gallstones, bile duct stricture, or malignancy

Contraindications

• Existing bowel perforation
• Unstable patient
• Anatomic abnormalities of gastrointestinal tract
• Altered gastrointestinal anatomy due to surgery
• Untreated coagulopathy

Complications

• Acute pancreatitis
• Endoscope-associated infection
• Bowel perforation

Cholecystectomy 

General explanation

• Surgical removal of the gallbladder via open surgery or laparoscope
  • Laparoscopic procedure is preferred in all cases, but conversion to open surgery may be required

Indication

• Elective treatment after endoscopic clearance of gallstones causing an acute episode of cholangitis 

Contraindications

• Previous abdominal surgery that precludes safe performance of procedure
• Severe local inflammation
• Unstable patient
• Untreated coagulopathy
• Generalized peritonitis
• Advanced cirrhosis or liver failure
• Previous gallbladder surgery
• Congestive heart failure
• Obstructive pulmonary disease

Complications

• Intra-abdominal abscess
• Peritonitis
• Bile leakage
• Common bile duct injuries

Comorbidities

• Primary sclerosing cholangitis
  • Progressive disorder characterized by chronic inflammation and fibrosis of the bile ducts leading to bile duct strictures 
  • May progress to cirrhosis, portal hypertension, and hepatic failure requiring liver transplantation 
  • Acute cholangitis is a common complication 
  • Management consists of initial antimicrobial therapy and drainage, and endoscopic dilatation or stenting of dominant stricture; long-term prophylactic antibiotics may be indicated for recurrent cholangitis
• Recurrent pyogenic cholangitis
  • Chronic, progressive condition characterized by intrahepatic duct stones, bile duct strictures or dilatation, and recurrent attacks of cholangitis
  • Associated with complications such as liver abscesses, cirrhosis, and cholangiocarcinoma
  • Episodes of cholangitis require urgent intervention and antibiotic treatment; definite management may include hepatic resection, bypass surgery, or liver transplantation

Complications

• Recurrent obstruction or cholangitis
• Acute pancreatitis
• Sepsis

Prognosis

• Prognosis depends on severity of illness, which can range from self-limiting to severe and potentially life-threatening 
• Most cases respond to initial medical management 
• Mortality rates have fallen in recent decades from over 50% before 1980 to between 2.7% and 10% after 2000 
• Early biliary drainage (within hours) is associated with less persistent organ failure and shorter length of stay for critically ill patients 
• Hypoalbuminemia, serum procalcitonin level greater than 0.5 nanograms/mL, interleukin-7 level less than 6.0 pg/mL, and high BMI are associated with increased mortality 

Prevention

• Acute cholangitis can be prevented by timely treatment of biliary obstruction 
• Recurrent gallstone-associated cholangitis can be prevented by cholecystectomy 

References

Kimura Y et al: TG13 current terminology, etiology, and epidemiology of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 20(1):8-23, 2013