7/10/2015

AcuteCholangitis:Background,Pathophysiology,Epidemiology

AcuteCholangitis
Author:TimothyMScott,DOChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...
Updated:Nov10,2014

Background
Acutecholangitisisabacterialinfectionsuperimposedonanobstructionofthebiliarytreemostcommonlyfroma
gallstone,butitmaybeassociatedwithneoplasmorstricture.

Pathophysiology
Themainfactorsinthepathogenesisofacutecholangitisarebiliarytractobstruction,elevatedintraluminal
pressure,andinfectionofbile.Abiliarysystemthatiscolonizedbybacteriabutisunobstructed,typicallydoesnot
resultincholangitis.Itisbelievedthatbiliaryobstructiondiminisheshostantibacterialdefenses,causesimmune
dysfunction,andsubsequentlyincreasessmallbowelbacterialcolonization.Althoughtheexactmechanismis
unclear,itisbelievedthatbacteriagainaccesstothebiliarytreebyretrogradeascentfromtheduodenumorfrom
portalvenousblood.Asaresult,infectionascendsintothehepaticducts,causingseriousinfection.Increasedbiliary
pressurepushestheinfectionintothebiliarycanaliculi,hepaticveins,andperihepaticlymphatics,leadingto
bacteremia(2540%).Theinfectioncanbesuppurativeinthebiliarytract.
Thebileisnormallysterile.Inthepresenceofgallbladderorcommonductstones(CBD),however,theincidenceof
bactibiliaincreases.ThemostcommonorganismsisolatedinbileareEscherichiacoli(27%),Klebsiellaspecies
(16%),Enterococcusspecies(15%),Streptococcusspecies(8%),Enterobacterspecies(7%),andPseudomonas
aeruginosa(7%).Organismsisolatedfrombloodculturesaresimilartothosefoundinthebile.Themostcommon
pathogensisolatedinbloodculturesareEcoli(59%),Klebsiellaspecies(16%),Pseudomonasaeruginosa(5%),and
Enterococcusspecies(4%).Inaddition,polymicrobialinfectioniscommonlyfoundinbilecultures(3087%)andless
frequentinbloodcultures(616%).Forrelatedpathophysiology,pleaseseetheCholelithiasisandCholecystitisand
BiliaryColicarticles.
Primarysclerosingcholangitisisachronicliverdiseasethatisthoughttobeduetoanautoimmunemechanism. [1]It
ischaracterizedbyinflammationandfibrosisoftheintrahepaticandextrahepaticbileducts.Thiscondition
ultimatelyleadstoportalhypertensionandcirrhosisoftheliverwiththeonlydefinitivetreatmentbeingaliver
transplant. [2]Formoreonthiscondition,pleaserefertothePrimarySclerosingCholangitisarticle.

Epidemiology
Frequency
UnitedStates
Cholangitisisrelativelyuncommon.Itoccursinassociationwithotherdiseasesthatcausebiliaryobstructionand
bactibilia(eg,afterendoscopicretrogradecholangiopancreatography[ERCP],13%ofpatientsdevelopcholangitis).
Riskisincreasedifdyeisinjectedretrograde.
International
Recurrentpyogeniccholangitis,sometimesreferredtoasOrientalcholangiohepatitis,isendemictoSoutheastAsia.
Itischaracterizedbymultipleoccurrencesofbiliarytractinfection,intrahepaticandextrahepaticbiliarystone
formation,hepaticabscesses,anddilatationandstricturingoftheintrahepaticandextrahepaticbileduct. [3]For
moreonthiscondition,pleaserefertotheRecurrentPyogenicCholangitisarticle.

Mortality/Morbidity
Prognosis
Theprognosisdependsonseveralfactors,includingthefollowing[4]:
Earlyrecognitionandtreatmentofcholangitis
Responsetotherapy
Underlyingmedicalconditionsofthepatient
Mortalityraterangesfrom510%,withahighermortalityrateinpatientswhorequireemergencydecompressionor
surgery.
Inpatientsrespondingtoantibiotictherapy,theprognosisisgood.
Morbidity/mortality
Mortalityfromcholangitisishighduetothepredispositioninpeoplewithunderlyingdisease.Historically,the
mortalityratewas100%.Withtheadventofendoscopicretrogradecholangiography,therapeuticendoscopic
sphincterotomy,stoneextraction,andbiliarystenting,themortalityratehassignificantlydeclinedtoapproximately
510%.
Thefollowingpatientcharacteristicsareassociatedwithhighermorbidityandmortalityrates:
Hypotension
Acuterenalfailure
Liverabscess
Cirrhosis
Inflammatoryboweldisease
Highmalignantstrictures
RadiologiccholangitisPostpercutaneoustranshepaticcholangiography
Femalegender
Ageolderthan50years
Failuretorespondtoantibioticsandconservativetherapy

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

1/3

7/10/2015

AcuteCholangitis:Background,Pathophysiology,Epidemiology

Advancedage,concurrentmedicalproblems,anddelayindecompressionincreasetheemergentoperativemortality
rate(1740%).
Themortalityrateofelectivesurgeryaftermedicalstabilizationissignificantlyless(approximately3%).
Inthepast,suppurativecholangitiswasthoughttohaveincreasedmorbidityhowever,prospectivestudieshavenot
foundthistobetrue.
Complications
Patientsareincreasinglylikelytohavecomplicationswithgreaterdegreesofillness,asfollows:
Liverfailure,hepaticabscesses,andmicroabscesses
Bacteremia(2540%)gramnegativesepsis
Acuterenalfailure
Catheterrelatedproblemsinpatientstreatedwithpercutaneousorendoscopicdrainageincludethefollowing:
Bleeding(intraabdominallyorpercutaneously)
Catheterrelatedsepsis
Fistulae
Bileleak(intraperitoneallyorpercutaneously)

Race
Cholangitisfrequentlyoccurssecondarytoagallstoneobstructingthecommonbileduct.Therefore,itcarriesthe
sameriskfactorsasthatofcholelithiasis.
PrevalenceofgallstonesishighestinfairskinnedpeopleofNorthernEuropeandescentaswellasinHispanic
populations,NativeAmericans,andPimaIndians.
Inaddition,certainAsianpopulationsandinhabitantsofcountrieswhereintestinalparasitesarecommonarealsoat
increasedrisk.Asiansaremorelikelytohaveprimarystonesduetochronicbiliaryinfections,parasites,bilestasis,
andbiliarystrictures.Recurrentpyogeniccholangitis(Orientalcholangiohepatitis)rarelyisobservedintheUnited
States.
Blackindividualswithsicklecelldiseaseareatincreasedrisk.

Sex
Althoughgallstonesaremorecommoninwomenthaninmen,themaletofemaleratioisequalincholangitis.

Age
Elderlypatientsaremorelikelytoprogressfromasymptomaticgallstonestoseriouscomplicationsofgallstonesand
cholangitis.
Suspectcholangitisinolderpatientspresentingwithsepsisandmentalstatuschanges.Elderlypatientsaremore
pronetogallstonesandCBDstonesand,therefore,cholangitis.
Themedianageatpresentationisbetween50and60years.

ContributorInformationandDisclosures
Author
TimothyMScott,DOChiefResident,DepartmentofEmergencyMedicine,DetroitMedicalCenter,Wayne
StateUniversitySchoolofMedicine
TimothyMScott,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,AmericanMedicalAssociation,AmericanOsteopathicAssociation,EmergencyMedicine
Residents&#039Association
Disclosure:Nothingtodisclose.
Coauthor(s)
AdamJRosh,MDAssistantProfessor,ProgramDirector,EmergencyMedicineResidency,Departmentof
EmergencyMedicine,DetroitReceivingHospital,WayneStateUniversitySchoolofMedicine
AdamJRosh,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.
ChiefEditor
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,
ProgramDirectorforEmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserve
UniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanHeartAssociation,AmericanThoracicSociety,ArkansasMedicalSociety,NewYorkAcademyof
Medicine,NewYorkAcademyofSciences,SocietyforAcademicEmergencyMedicine,AmericanAcademyof
EmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeofEmergencyPhysicians,
AmericanCollegeofPhysicians
Disclosure:Nothingtodisclose.
Acknowledgements
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,
MartinLutherKingJr/DrewMedicalCenter

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

2/3

7/10/2015

AcuteCholangitis:Background,Pathophysiology,Epidemiology

Disclosure:Nothingtodisclose.
JeffreyAManko,MDAssistantProfessorofEmergencyMedicine,Director,EmergencyMedicineResidency
Program,ConsultingStaff,EmergencyMedicineServices,NewYorkUniversity/BellevueMedicalCenter
JeffreyAManko,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,CouncilofEmergencyMedicineResidencyDirectors,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
SallySanten,MDProgramDirector,AssistantProfessor,DepartmentofEmergencyMedicine,Vanderbilt
University
SallySanten,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.

References
1. AronJH,BowlusCL.Theimmunobiologyofprimarysclerosingcholangitis.SeminImmunopathol.2009
Sep.31(3):38397.[Medline].[FullText].
2. KashyapR,MantryP,SharmaR,etal.Comparativeanalysisofoutcomesinlivinganddeceaseddonor
livertransplantsforprimarysclerosingcholangitis.JGastrointestSurg.2009Aug.13(8):14806.[Medline].
3. vanErpecumKJ.Gallstonedisease.Complicationsofbileductstones:Acutecholangitisandpancreatitis.
BestPractResClinGastroenterol.2006.20(6):113952.[Medline].
4. RosingDK,DeVirgilioC,NguyenAT,ElMasryM,KajiAH,StabileBE.Cholangitis:analysisofadmission
prognosticindicatorsandoutcomes.AmSurg.2007Oct.73(10):94954.[Medline].
5. KinneyTP.Managementofascendingcholangitis.GastrointestEndoscClinNAm.2007Apr.17(2):289
306,vi.[Medline].
6. JabaraB,FargenKM,BeechS,SlakeyDR.Diagnosisofcholangiocarcinoma:acaseseriesandliterature
review.JLaStateMedSoc.2009MarApr.161(2):8994.[Medline].
7. AttasaranyaS,FogelEL,LehmanGA.Choledocholithiasis,ascendingcholangitis,andgallstone
pancreatitis.MedClinNorthAm.2008Jul.92(4):92560,x.[Medline].
8. RustemovicN,CukovicCavkaS,OpacicM,etal.Endoscopicultrasoundelastographyasamethodfor
screeningthepatientswithsuspectedprimarysclerosingcholangitis.EurJGastroenterolHepatol.2010
Jun.22(6):74853.[Medline].
9. IorgulescuA,SanduI,TurcuF,IordacheN.PostERCPacutepancreatitisanditsriskfactors.JMedLife.
2013Mar15.6(1):10913.[Medline].[FullText].
10. SharmaBC,AgarwalN,SharmaP,SarinSK.Endoscopicbiliarydrainageby7Fror10Frstent
placementinpatientswithacutecholangitis.DigDisSci.2009Jun.54(6):13559.[Medline].
11. ItoiT,KawaiT,SofuniA,etal.Efficacyandsafetyof1steptransnasalendoscopicnasobiliarydrainage
forthetreatmentofacutecholangitisinpatientswithpreviousendoscopicsphincterotomy(withvideos).
GastrointestEndosc.2008Jul.68(1):8490.[Medline].
12. ParkTY,ChoiJS,SongTJ,etal.Earlyoralantibioticswitchcomparedwithconventionalintravenous
antibiotictherapyforacutecholangitiswithbacteremia.DigDisSci.2014Nov.59(11):27906.[Medline].
MedscapeReference2011WebMD,LLC

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

3/3