The cholangitis is an infection and inflammation of the bile ducts usually starts in extrahepatic bile but which can also affect the intrahepatic tract. It is generally due to an obstruction of the bile ducts due to the exit of stones from the gallbladder that obstruct the passage of bile.
It can also be caused by bile duct stenosis, such as infectious processes associated with HIV, by tumors, congenital malformations that compromise the bile ducts, by a surgical complication of cholelithiasis treatment or a complication of endoscopic treatments.
Cholangiogram of a primary sclerosing cholangitis (Source: Joy Worthington, Roger Chapman / CC BY (https://creativecommons.org/licenses/by/2.0) via Wikimedia Commons)
The liver makes bile and discharges it into the bile ducts. The bile ducts are tubes that carry bile from the liver to the duodenum. There are intrahepatic and extrahepatic bile ducts. The gallbladder stores bile and connects through the cystic duct to the extrahepatic bile ducts.
The intrahepatic bile ducts are made up of a series of canaliculi that generally converge into two ducts, the right hepatic duct and the left hepatic duct.
The extrahepatic bile ducts include the common hepatic duct and the common bile duct. The common hepatic duct is formed by the union of the right and left hepatic ducts. The common bile duct is the junction of the common hepatic duct with the cystic duct.
The common bile duct empties together with the pancreatic duct into the duodenum. These may be separated or joined at or very close to Vater's ampulla. Normally in the fasting state, the common bile duct is closed at its end due to the closure of the sphincter of Oddi.
When foods rich in fat and protein are eaten, the sphincter of Oddi opens and bile flows through the bile ducts into the duodenum. If there is an obstruction, the bile ducts will not be able to drain, pressure increases and bacteria can colonize the mucosa, causing cholangitis.
Cholangitis requires antibiotic treatment, decompression, and drainage of the bile ducts. It is a medical emergency that requires hospitalization.
Symptoms
Cholangitis is characterized by the "Charcot Triad", which includes abdominal pain, fever, and yellowing of the skin and mucosa (jaundice). The pain is usually triggered by eating foods that are high in fat or grains (beans).
The pain can be intense and is generally localized to the right upper quadrant and epigastrium, radiating to the back and right shoulder. It can be accompanied by nausea and vomiting, and subsides with antispasmodics and pain relievers.
Initially, jaundice may be accompanied by an increase in urine color (hypercoluria), but as biliary obstruction progresses, hypocholia may appear.
The fever appears during the evolution of the picture, it can be a high fever with chills. If cholangitis is not treated in the early stages, it can evolve into a septic picture that affects several organs. Among the most frequently affected organs is the kidney.
Laboratory tests generally show an increase in leukocytes and C-reactive protein. It can cause alterations in liver function, which is why enzymes are increased, bilirubin values are altered.
Abdominal imaging studies reveal a dilated bile duct and the presence of stone obstruction, stricture, or compression.
The symptoms, the alteration of the laboratory values described and the images of dilation and obstruction are the pillars that confirm the diagnosis of cholangitis.
Degrees
Cholangitis is classified into acute, recurrent, sclerosing cholangitis associated with HIV and primary sclerosing cholangitis. Longmire's classification of acute cholangitis is also used, which classifies them into five types.
- Acute cholangitis secondary to acute cholecystitis
- Acute suppurative cholangitis
- Acute obstructive suppurative cholangitis
- Acute suppurative cholangitis accompanied by liver abscess
- Acute non-suppurative cholangitis (the term suppurative refers to the presence of pus)
Acute cholangitis is classified according to the severity of the condition in three degrees. Defining the degree of severity is very important for therapeutic behavior.
-Grade I, mild or simple in which a mild feverish picture appears with very few laboratory alterations.
-Grade II or moderate in this grade two or more of the following alterations are associated: fever greater than or equal to 39 ⁰C, leukocytosis or leukopenia, age greater than or equal to 75 years, bilirubinemia greater than or equal to 5 mg%, hypoalbuminemia.
Grade II cholangitis usually rapidly progresses to septic conditions if decompression and biliary drainage is not done early.
-Grade III or severe is called septic cholangitis. Initially it presents with multiorgan dysfunction with hemodynamic, renal, respiratory, hematological, hepatic and neurological alterations.
Causes
50% of cholangitis are associated with stones in the gallbladder that move into the bile ducts and obstruct them. This obstruction increases the pressure in the biliary system, causes dilation of the ducts and colonization of the mucosa by intestinal bacteria.
However, this condition can occur due to obstructions of other origins such as benign or malignant tumors in situ or of adjacent organs that compress some portion of the biliary drainage routes.
Another no less frequent cause is the stenosis generated due to previous infectious processes, very frequent in patients with HIV, as a consequence of complications that occurred during a previous surgical event or with the mismanagement of endoscopic interventions of the bile ducts.
The microorganisms most frequently found in cholangitis are E. Coli bacteria, enterococci, members of the species Bacteroides fragilis, and Klebsiella pneumoniae.
Complications
One of the most serious complications is the rupture of the bile duct wall with the blood dissemination of bacteria and / or their toxins and bile. This produces biliary sepsis with dysfunction of many organs and systems that can lead to the death of the patient.
Local complications include liver abscess, pancreatitis, and primary biliary cirrhosis. General complications include septic shock, coma, and death.
Treatments
Cholangitis management scheme (Source: ArturoJuárezFlores / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0) via Wikimedia Commons)
Diagnosis must be made, and treatment depends on the degree of severity of the cholangitis. However, in all cases there is an indication for hospitalization, suspension of the oral route and antibiotic treatment by intravenous or intramuscular route.
In the case of grade I, the treatment indicated above is carried out and a 48-hour observation period is expected. If the condition remits, as occurs in most cases, antibiotic treatment is followed for 7 to 10 days and the patient is referred for subsequent monitoring and treatment of the initial cause (gallbladder stones).
In the case of grade II, we proceed with hospitalization, antibiotics and suspension of the oral route. Immediate decompression and drainage is performed endoscopically or surgically depending on the cause or the availability of the health center.
In grade III, the patient generally requires special care. Sometimes it requires intensive care for the regulation and treatment of the different organic failures. Treatment also includes antibiotics and once the patient is stabilized, the obstruction must be corrected.
References
- Hui, CK, Lai, KC, Yuen, MF, Ng, M., Lai, CL, & Lam, SK (2001). Acute cholangitis-predictive factors for emergency ERCP. Alimentary pharmacology & therapeutics, 15 (10), 1633-1637.
- Khashab, MA, Tariq, A., Tariq, U., Kim, K., Ponor, L., Lennon, AM,… & Hutfless, S. (2012). Delayed and unsuccessful endoscopic retrograde cholangiopancreatography are associated with worse outcomes in patients with acute cholangitis. Clinical gastroenterology and hepatology, 10 (10), 1157-1161.
- Lee, JG (2009). Diagnosis and management of acute cholangitis. Nature Reviews Gastroenterology & Hepatology, 6 (9), 533.
- Netter, FH (2014). Atlas of human anatomy, Professional Edition EBook: including Netter Reference. com Access with full downloadable image Bank. Elsevier Health Sciences.
- Petrov, MS, van Santvoort, HC, Besselink, MG, van der Heijden, GJ, van Erpecum, KJ, & Gooszen, HG (2008). Early endoscopic retrograde cholangiopancreatography versus conservative management in acute biliary pancreatitis without cholangitis: a meta-analysis of randomized trials.