Acute Cholangitis

Overview

Acute cholangitis is an infection of the bile ducts, the tubes that carry bile from the liver and gallbladder into the small intestine. It usually develops when a duct becomes blocked, most often by a gallstone, causing bile to back up. Stagnant bile behind the blockage becomes a breeding ground for bacteria, and the infection can quickly spread into the bloodstream.

Because it can progress rapidly to a serious, life-threatening illness, acute cholangitis is treated as a medical emergency. It classically causes a combination of fever, yellowing of the skin and eyes, and pain in the upper-right abdomen. Prompt antibiotics and a procedure to relieve the blockage and drain the infected bile are the keys to recovery.

Symptoms

Doctors often look for a classic group of three symptoms, sometimes called Charcot's triad.

• Fever, often with shaking chills
• Jaundice, a yellowing of the skin and the whites of the eyes
• Pain in the upper-right or upper-middle abdomen

Other signs include dark urine, pale stools, nausea, and vomiting. In severe infection, a person may also develop confusion and low blood pressure, which point to a dangerous, body-wide reaction (sepsis) that requires emergency treatment without delay.

Causes

Acute cholangitis nearly always results from a blockage of the bile ducts combined with bacterial infection. Common causes include:

• Gallstones that pass from the gallbladder into the main bile duct and lodge there.
• Strictures, or narrowing of the ducts from scarring or inflammation.
• Tumors of the bile ducts, pancreas, or nearby structures that press on or block the ducts.
• Complications of procedures on the bile ducts, such as stent placement or imaging studies.

When bile cannot flow freely, bacteria multiply and the duct becomes infected.

Risk Factors

• Gallstones or a history of gallstone disease
• Older age
• Previous bile duct surgery or procedures
• Narrowing or scarring of the bile ducts
• Tumors of the bile ducts or pancreas
• Prior episodes of cholangitis

Diagnosis

Because cholangitis can worsen fast, diagnosis is made quickly using:

• Blood tests: to detect infection and abnormal liver and bile (cholestasis) markers.
• Ultrasound or CT scan: to look for blocked or widened bile ducts and gallstones.
• MRCP: a special MRI of the bile ducts that shows blockages in detail.
• ERCP: a procedure using an endoscope that both confirms and treats the blockage by draining bile and removing stones.

Treatment

Treatment has two urgent goals: control the infection and relieve the blockage so bile can drain. Care is given in the hospital and includes:

• Antibiotics and fluids through a vein, started promptly to fight the infection and support blood pressure.
• Biliary drainage: usually done with ERCP to remove the stone or place a stent that opens the duct; sometimes a drainage tube is placed through the skin.
• Treating the cause: once stable, the underlying problem, such as gallstones, may be addressed, often by removing the gallbladder.

With rapid treatment, most people recover, but delays raise the risk of sepsis and other serious complications.

Prevention

• Have known gallstones evaluated, especially after a previous attack
• Follow up on any bile duct narrowing or prior procedures
• Seek care early for upper-right belly pain with fever or jaundice
• Manage conditions that affect the bile ducts as advised by your provider
• Attend recommended follow-up after gallbladder or bile duct surgery

When to See a Doctor

Acute cholangitis is an emergency. Seek immediate care if you have:

• Fever with shaking chills
• Yellowing of the skin or eyes
• Upper-right or upper-middle belly pain
• Dark urine and pale stools
• Confusion, dizziness, rapid heartbeat, or low blood pressure

The combination of fever, jaundice, and belly pain is a warning sign that needs urgent evaluation, because the infection can spread to the bloodstream quickly.

Related Topics

Frequently Asked Questions

References

1. Mayo Clinic. Cholangitis.
2. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Gallstones.
3. MedlinePlus, U.S. National Library of Medicine. Cholangitis.
4. American Society for Gastrointestinal Endoscopy (ASGE). ERCP.