7/10/2015 Acute Cholangitis: Background, Pathophysiology, Epidemiology

http://emedicine.medscape.com/article/774245overview#showall 1/3

Acute CholangitisAuthor: Timothy M Scott, DO; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...

Updated: Nov 10, 2014

BackgroundAcute cholangitis is a bacterial infection superimposed on an obstruction of the biliary tree most commonly from agallstone, but it may be associated with neoplasm or stricture.

PathophysiologyThe main factors in the pathogenesis of acute cholangitis are biliary tract obstruction, elevated intraluminalpressure, and infection of bile. A biliary system that is colonized by bacteria but is unobstructed, typically does notresult in cholangitis. It is believed that biliary obstruction diminishes host antibacterial defenses, causes immunedysfunction, and subsequently increases small bowel bacterial colonization. Although the exact mechanism isunclear, it is believed that bacteria gain access to the biliary tree by retrograde ascent from the duodenum or fromportal venous blood. As a result, infection ascends into the hepatic ducts, causing serious infection. Increased biliarypressure pushes the infection into the biliary canaliculi, hepatic veins, and perihepatic lymphatics, leading tobacteremia (2540%). The infection can be suppurative in the biliary tract.

The bile is normally sterile. In the presence of gallbladder or common duct stones (CBD), however, the incidence ofbactibilia increases. The most common organisms isolated in bile are Escherichia coli (27%), Klebsiella species(16%), Enterococcus species (15%), Streptococcus species (8%), Enterobacter species (7%), and Pseudomonasaeruginosa (7%). Organisms isolated from blood cultures are similar to those found in the bile. The most commonpathogens isolated in blood cultures are E coli (59%), Klebsiella species (16%), Pseudomonas aeruginosa (5%), andEnterococcus species (4%). In addition, polymicrobial infection is commonly found in bile cultures (3087%) and lessfrequent in blood cultures (616%). For related pathophysiology, please see the Cholelithiasis and Cholecystitis andBiliary Colic articles.

Primary sclerosing cholangitis is a chronic liver disease that is thought to be due to an autoimmune mechanism.[1] Itis characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts. This conditionultimately leads to portal hypertension and cirrhosis of the liver with the only definitive treatment being a livertransplant.[2] For more on this condition, please refer to the Primary Sclerosing Cholangitis article.

Epidemiology

Frequency

United States

Cholangitis is relatively uncommon. It occurs in association with other diseases that cause biliary obstruction andbactibilia (eg, after endoscopic retrograde cholangiopancreatography [ERCP], 13% of patients develop cholangitis).Risk is increased if dye is injected retrograde.

International

Recurrent pyogenic cholangitis, sometimes referred to as Oriental cholangiohepatitis, is endemic to Southeast Asia.It is characterized by multiple occurrences of biliary tract infection, intrahepatic and extrahepatic biliary stoneformation, hepatic abscesses, and dilatation and stricturing of the intrahepatic and extrahepatic bile duct.[3] Formore on this condition, please refer to the Recurrent Pyogenic Cholangitis article.

Mortality/Morbidity

Prognosis

The prognosis depends on several factors, including the following[4] :

Early recognition and treatment of cholangitisResponse to therapyUnderlying medical conditions of the patient

Mortality rate ranges from 510%, with a higher mortality rate in patients who require emergency decompression orsurgery.

In patients responding to antibiotic therapy, the prognosis is good.

Morbidity/mortality

Mortality from cholangitis is high due to the predisposition in people with underlying disease. Historically, themortality rate was 100%. With the advent of endoscopic retrograde cholangiography, therapeutic endoscopicsphincterotomy, stone extraction, and biliary stenting, the mortality rate has significantly declined to approximately510%.

The following patient characteristics are associated with higher morbidity and mortality rates:

HypotensionAcute renal failureLiver abscessCirrhosisInflammatory bowel diseaseHigh malignant stricturesRadiologic cholangitis – Post percutaneous transhepatic cholangiographyFemale genderAge older than 50 yearsFailure to respond to antibiotics and conservative therapy

7/10/2015 Acute Cholangitis: Background, Pathophysiology, Epidemiology

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Advanced age, concurrent medical problems, and delay in decompression increase the emergent operative mortalityrate (1740%).

The mortality rate of elective surgery after medical stabilization is significantly less (approximately 3%).

In the past, suppurative cholangitis was thought to have increased morbidity; however, prospective studies have notfound this to be true.

Complications

Patients are increasingly likely to have complications with greater degrees of illness, as follows:

Liver failure, hepatic abscesses, and microabscessesBacteremia (2540%); gramnegative sepsisAcute renal failure

Catheterrelated problems in patients treated with percutaneous or endoscopic drainage include the following:

Bleeding (intraabdominally or percutaneously)Catheterrelated sepsisFistulaeBile leak (intraperitoneally or percutaneously)

Race

Cholangitis frequently occurs secondary to a gallstone obstructing the common bile duct. Therefore, it carries thesame risk factors as that of cholelithiasis.

Prevalence of gallstones is highest in fairskinned people of Northern European descent as well as in Hispanicpopulations, Native Americans, and Pima Indians.

In addition, certain Asian populations and inhabitants of countries where intestinal parasites are common are also atincreased risk. Asians are more likely to have primary stones due to chronic biliary infections, parasites, bile stasis,and biliary strictures. Recurrent pyogenic cholangitis (Oriental cholangiohepatitis) rarely is observed in the UnitedStates.

Black individuals with sickle cell disease are at increased risk.

Sex

Although gallstones are more common in women than in men, the maletofemale ratio is equal in cholangitis.

Age

Elderly patients are more likely to progress from asymptomatic gallstones to serious complications of gallstones andcholangitis.

Suspect cholangitis in older patients presenting with sepsis and mental status changes. Elderly patients are moreprone to gallstones and CBD stones and, therefore, cholangitis.

The median age at presentation is between 50 and 60 years.

Contributor Information and DisclosuresAuthorTimothy M Scott, DO Chief Resident, Department of Emergency Medicine, Detroit Medical Center, WayneState University School of Medicine

Timothy M Scott, DO is a member of the following medical societies: American College of EmergencyPhysicians, American Medical Association, American Osteopathic Association, Emergency MedicineResidents' Association

Disclosure: Nothing to disclose.

Coauthor(s)Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, Department ofEmergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine,American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor BoardFrancisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center Collegeof Pharmacy; EditorinChief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment.

Chief EditorBarry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine,Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western ReserveUniversity School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha,American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy ofMedicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy ofEmergency Medicine, American College of Chest Physicians, American College of Emergency Physicians,American College of Physicians

Disclosure: Nothing to disclose.

AcknowledgementsEugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of EmergencyMedicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine,Martin Luther King Jr/Drew Medical Center

7/10/2015 Acute Cholangitis: Background, Pathophysiology, Epidemiology

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Medscape Reference © 2011 WebMD, LLC

Disclosure: Nothing to disclose.

Jeffrey A Manko, MD A ssistant Professor of Emergency Medicine, Director, Emergency Medicine ResidencyProgram, Consulting Staff, Emergency Medicine Services, New York University/Bellevue Medical Center

Jeffrey A Manko, MD is a member of the following medical societies: American College of EmergencyPhysicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sally Santen, MD Program Director, Assistant Professor, Department of Emergency Medicine, VanderbiltUniversity

Sally Santen, MD is a member of the following medical societies: American College of Emergency Physiciansand Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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