7/10/2015 Acute Cholangitis Clinical Presentation: History, Physical, Causes

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

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

Updated: Nov 10, 2014

HistoryIn 1877, Charcot described cholangitis as a triad of findings of right upper quadrant (RUQ) pain, fever, and jaundice.The Reynolds pentad adds mental status changes and sepsis to the triad. A spectrum of cholangitis exists, rangingfrom mild symptoms to fulminant overwhelming sepsis. With septic shock, the diagnosis can be missed in up to25% of patients. Consider cholangitis in any patient who appears septic, especially in patients who are elderly,jaundiced, or who have abdominal pain. A history of abdominal pain or symptoms of gallbladder colic may be a clueto the diagnosis.

Symptoms include the following:

Charcot's triad consists of fever, RUQ pain, and jaundice. It is reported in up to 5070% of patients withcholangitis. However, recent studies believe it is more likely to be present in 1520% of patients.Fever is present in approximately 90% of cases.Abdominal pain and jaundice is thought to occur in 70% and 60% of patients, respectively.Patients present with altered mental status 1020% of the time and hypotension approximately 30% of thetime. These signs, combined with Charcot's triad, constitute Reynolds pentad.Consequently, many patients with ascending cholangitis do not present with the classic signs and symptoms.[5]

Most patients complain of RUQ pain; however, some patients (ie, elderly persons) are too ill to localize thesource of infection.

Other symptoms include the following:

JaundiceFever, chills, and rigorsAbdominal painPruritusAcholic or hypocholic stoolsMalaise

The patient's medical history may be helpful. For example, a history of the following increases the risk ofcholangitis:

Gallstones, CBD stonesRecent cholecystectomyEndoscopic manipulation or ERCP, cholangiogramHistory of cholangitisHistory of HIV or AIDS: AIDSrelated cholangitis is characterized by extrahepatic biliary edema, ulceration,and obstruction. The etiology is uncertain, but it may be related to cytomegalovirus or Cryptosporidiuminfections. The management of this condition is described below, although decompression is usually notnecessary.

PhysicalIn general, patients with cholangitis are quite ill and frequently present in septic shock without an apparent source ofthe infection.

Physical examination may reveal the following:

Fever (90%), although elderly patients may have no feverRUQ tenderness (65%)Mild hepatomegalyJaundice (60%)Mental status changes (1020%)SepsisHypotension (30%)TachycardiaPeritonitis (uncommon, and should lead to a search for an alternative diagnosis)

CausesIn Western countries, choledocholithiasis is the most common cause of acute cholangitis, followed by ERCP andtumors.

Any condition that leads to stasis or obstruction of bile in the CBD, including benign or malignant stricture, parasiticinfection, or extrinsic compression by the pancreas, can result in bacterial infection and cholangitis. Partialobstruction is associated with a higher rate of infection than complete obstruction.

Common bile duct stones

CBD stones predispose patients to cholangitis. Approximately 1015% of patients with cholecystitis have CBDstones.

Approximately 1% of patients post cholecystectomy have retained CBD stones. Most CBD stones are immediatelysymptomatic, while some remain asymptomatic for years.

Some CBD stones are formed primarily rather than secondarily to gallstones.

Obstructive tumors

Obstructive tumors cause cholangitis. Partial obstruction is associated with an increased rate of infection compared

7/10/2015 Acute Cholangitis Clinical Presentation: History, Physical, Causes

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with that of complete neoplastic obstruction. Obstructive tumors include the following:

Pancreatic cancerCholangiocarcinoma[6]Ampullary cancerPorta hepatis tumors or metastasis

Other causes

Additional causes of cholangitis include the following:

Strictures or stenosisEndoscopic manipulation of the CBDCholedochoceleSclerosing cholangitis (from biliary sclerosis)AIDS cholangiopathyAscaris lumbricoides infections

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

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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