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Acute Cholangitis - an Update

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Acute Cholangitis - an Update Submit a Manuscript: http://www.f6publishing.com World J Gastrointest Pathophysiol 208 February 5; 9(): -7 DOI: 0.429/wjgp.v9.i. ISSN 250-5330 (online) MINIREVIEWS Acute cholangitis - an update Monjur Ahmed Monjur Ahmed, Division of Gastroenterology and Hepatology, of gallstones. Biliary obstruction of any cause is the Department of Internal Medicine, Thomas Jefferson University, main predisposing factor. Diagnosis is established by Philadelphia, PA 19107, United States the presence of clinical features, laboratory results and imaging studies. The treatment modalities include Author contributions: Ahmed M solely contributed to this administration of intravenous fluid, antibiotics, and work. drainage of the bile duct. The outcome is good if the treatment is started early, otherwise it could be grave. Conflict-of-interest statement: None to declare. Open-Access: This article is an open-access article which was Key words: Acute cholangitis; Ascending cholangitis; selected by an in-house editor and fully peer-reviewed by external Biliary infection; Hepatic fever; Infection of the bile reviewers. It is distributed in accordance with the Creative duct Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this © The Author(s) 2018. Published by Baishideng Publishing work non-commercially, and license their derivative works on Group Inc. All rights reserved. different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/ licenses/by-nc/4.0/ Core tip: Acute cholangitis is a serious medical problem unless treated early. High clinical suspicion is essential Manuscript source: Invited manuscript to diagnose this condition. The different diagnostic criteria, treatment options, including different modalities Correspondence to: Monjur Ahmed, MD, FRCP, Division of biliary drainage, and prognosis are described in this of Gastroenterology and Hepatology, Department of Internal article. Medicine, Thomas Jefferson University, 132 South 10th Street, Suite 468, Main Building, Philadelphia, PA 19107, United States. [email protected] Ahmed M. Acute cholangitis - an update. World J Gastrointest Telephone: +1-215-9521493 Pathophysiol 2018; 9(1): 1-7 Available from: URL: http://www. Fax: +1-215-7551850 wjgnet.com/2150-5330/full/v9/i1/1.htm DOI: http://dx.doi. org/10.4291/wjgp.v9.i1.1 Received: April 6, 2017 Peer-review started: April 10, 2017 First decision: May 26, 2017 Revised: July 5, 2017 INTRODUCTION Accepted: October 30, 2017 Article in press: October 30, 2017 Acute cholangitis is a clinical entity caused by bacterial Published online: February 15, 2018 infection of the biliary system, most commonly secondary to partial or complete obstruction of the bile duct or hepatic ducts. The diagnosis is established by the characteristic clinical symptoms and signs of Abstract infection, abnormal laboratory studies suggestive of Acute cholangitis is bacterial infection of the extra- infection and biliary obstruction, and abnormal imaging hepatic biliary system. As it is caused by gallstones studies suggestive of biliary obstruction[1]. The main blocking the common bile duct in most of the cases, its importance of this condition is that it is a very treatable prevalence is greater in ethnicities with high prevalence condition if treated appropriately, but the mortality WJGP|www.wjgnet.com February 5, 208|Volume 9|Issue | Ahmed M. Acute cholangitis lead to cirrhosis of the liver, which is a risk factor for gallstone formation. EPIDEMIOLOGY The prevalence of cholelithiasis varies in different ethnicities. Gallstones are found in 10% to 15% of the white population in the United States. It is much more prevalent in native Americans (60%-70%) and Hispanics but less common in Asians and African Americans[8]. Many patients get admitted to the hospital with gallstone disease and 6% to 9% of them are diagnosed with acute cholangitis[9]. Males and females Figure 1 Pus seen extruding from the ampulla of Vater. are equally affected. The average age of patients presenting with acute cholangitis is 50 to 60 years. Less than 200000 cases of cholangitis occur per year in the can be high if there is delay in treatment. There are United States. other varieties of cholangitis, which include primary biliary cholangitis, primary sclerosing cholangitis, IgG4- related autoimmune cholangitis and recurrent pyogenic PATHOPHYSIOLOGY [2] cholangitis or Oriental cholangiohepatitis . We will be Biliary obstruction is an important factor in the exclusively discussing here acute bacterial cholangitis, pathogenesis of cholangitis. When bile flow occurs, also called ascending cholangitis. The term ascending presence of bacteria in the bile is not that significant cholangitis comes from the migration of bacteria from because bacterial concentration does not increase and the duodenum into the common bile duct. But, rarely, the intraductal pressure does not increase. Normally, translocation of bacteria from the portal vein into the there are different defensive mechanisms to prevent bile duct can also occur. cholangitis. The bile salts have bacteriostatic activity and the biliary epithelium secretes IgA and mucous which ETIOLOGY probably act as anti-adherent factors. Kupffer cells on the biliary epithelium and the tight junction between The biliary obstruction is most commonly caused by the cholangiocytes prevent translocation of bacteria choledocholithiasis. Other causes of obstruction include from the hepatobiliary system into the portal venous benign or malignant stricture of the bile duct or hepatic system. Normal bile flow flushes out any bacteria into ducts, pancreatic cancer, ampullary adenoma or the duodenum. cancer, porta hepatis tumor or metastasis, biliary stent The sphincter of Oddi also prevents any migration obstruction (due to microbial biofilm formation, biliary of bacteria from the duodenum into the biliary system. sludge deposition and duodenal reflux of food content), In case of biliary obstruction, bile becomes stagnant in primary sclerosing cholangitis, amyloid deposition in the the biliary system, the intraductal pressure increases, [3] biliary system , Mirizzi syndrome (gallstone impacted the tight junction between cholangiocytes widen, in cystic duct or neck of the gall bladder causing Kupffer cells malfunction and the production of IgA compression on common bile duct or common hepatic is decreased[10]. “Choledochal pressure” plays an duct), Lemmel’s syndrome (peri-ampullary diverticulum important role in the pathogenesis of acute cholangitis. causing distal biliary obstruction), round worm (Ascaris The normal biliary ductal pressure is 7 to 14 cm of water lumbricoides) or tapeworm (Taenia saginata) infestation (H2O). When the intraductal pressure exceeds 25 cm [4] of the bile duct , acquired immunodeficiency syndrome of H2O, cholangiovenous and cholangiolymphatic reflux (commonly known as AIDS) cholangiopathy and can occur, leading to bacteremia and endotoxinemia[11]. [5] strictured bilioenteric anastomoses . Choledochocele Besides this, systemic release of inflammatory and narrow-caliber bile duct are other risk factors mediators like tumor necrosis factor (TNF), soluble TNF for acute cholangitis. Recently, there was an receptors, interleukin (IL)-1, IL-6 and IL-10 leads to outbreak of cholangitis due to carbapenem-resistant profound hemodynamic compromise. Enterobacteriaceae (CRE) as a result of exposure The most frequently found pathogens isolated in acute to contaminated duodenoscope[6]. Post-endoscopic cholangitis are coliform organisms[12,13]. These include retrograde cholangiopancreatography (ERCP) acute Escherechia coli (25%-50%), Klebsiella species cholangitis can occur in 0.5% to 2.4% cases (Figure (15%-20%), Enterococcus species (10%-20%) 1)[7]. As cholelithiasis is the most important risk factor, and Enterobacter species (5%-10%). Sometimes, the same risk factors may play important roles in the anaerobic bacteria like Bacteroids fragilis and development of acute cholangitis, particularly high fat Clostridium perfringens can also cause acute cholangitis, (triglyceride) intake, sedentary life styles, obesity and particularly in patients with previous biliary surgery rapid weight loss. Heavy alcohol consumption may and in the elderly population[14]. Parasitic infestation WJGP|www.wjgnet.com 2 February 5, 208|Volume 9|Issue | Ahmed M. Acute cholangitis of the biliary system by the liver flukes Clonorchis sinensis, Opisthorchis viverrini and Opisthorchis felineus and the roundworm Ascaris lumbricoides may lead to cholangitis[15]. CLINICAL PRESENTATION The presentation depends on the severity of cholangitis. Classically, patients present with high fever persisting for more than 24 h, abdominal pain and jaundice (Charcot’s triad or hepatic fever). The right upper quadrant abdominal pain is generally mild. When the cholangitis becomes more severe, patients become hypotensive and confused (Reynold’s Figure 2 Drainage of pus after biliary stenting during endoscopic retrograde pentad). Charcot’s triad has low sensitivity (26.4%) and cholangiopancreatography. high specificity (95.9%). Although the presence of Charcot’s triad is suggestive of acute cholangitis, it is tachycardia, hypotension, jaundice, right upper quadrant not diagnostic. Charcot’s triad is present in 26.4% to or epigastric tenderness and altered mental status. 72% of patients with acute cholangitis[16]. Severity of acute cholangitis: two clinical factors To
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