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Cholangitis – Causes, Symptoms and Treatment

Cholangitis is an inflammation of the bile ducts, most often caused by a bacterial infection. It can be acute or chronic and requires prompt medical attention.

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Things worth knowing about "Cholangitis"

Cholangitis is an inflammation of the bile ducts, most often caused by a bacterial infection. It can be acute or chronic and requires prompt medical attention.

What is Cholangitis?

Cholangitis refers to an inflammation of the bile ducts, the channels that carry bile from the liver to the small intestine. It can occur in acute or chronic form and is often associated with impaired bile flow. Without timely treatment, acute cholangitis can become life-threatening, making early diagnosis and therapy essential.

Causes

The most common cause of cholangitis is a bacterial infection, typically triggered by an obstruction (blockage) of the bile ducts. Common causes include:

Gallstones (choledocholithiasis): Stones lodged in the bile duct that block bile flow
Bile duct strictures: Narrowing caused by scar tissue or tumors
Tumors: Such as cholangiocarcinoma (bile duct cancer) or pancreatic head cancer
Parasitic infections: In certain parts of the world (e.g., liver flukes)
Primary sclerosing cholangitis (PSC): A chronic inflammatory autoimmune disease of the bile ducts
Primary biliary cholangitis (PBC): An autoimmune disease affecting the small intrahepatic bile ducts

Symptoms

The classic symptom triad of acute cholangitis is known as Charcot's triad:

Fever with chills
Jaundice: Yellowing of the skin and eyes
Right upper abdominal pain: Below the right rib cage

In severe cases, this may expand to the Reynolds pentad, which additionally includes altered mental status and septic shock. Chronic forms often progress more gradually, presenting with fatigue, itching, and slowly worsening jaundice.

Diagnosis

Diagnosis of cholangitis is based on a combination of clinical examination, laboratory tests, and imaging:

Blood count and liver function tests: Elevated inflammatory markers (CRP, leukocytes) and cholestasis parameters (bilirubin, alkaline phosphatase, GGT)
Blood cultures: To detect bacteria in the bloodstream (bacteremia/sepsis)
Ultrasound (sonography): The first-line imaging method for evaluating the bile ducts and liver
MRCP (Magnetic Resonance Cholangiopancreatography): Non-invasive visualization of the bile ducts using MRI
ERCP (Endoscopic Retrograde Cholangiopancreatography): An invasive procedure that can also be used therapeutically

Treatment

Treatment depends on the underlying cause and the severity of the condition:

Medical Treatment

Antibiotics: Intravenous antibiotics to combat bacterial infection (e.g., cephalosporins, piperacillin/tazobactam)
Ursodeoxycholic acid: Used in chronic forms such as PBC to slow disease progression
Immunosuppressants: For autoimmune bile duct diseases

Interventional and Surgical Treatment

ERCP with stone extraction or stent placement: To remove gallstones or bridge strictures
Percutaneous transhepatic cholangiodrainage (PTCD): Bile drainage through the skin when endoscopic therapy is not feasible
Surgery: For tumors or complex anatomical situations

Liver Transplantation

In the end stage of primary sclerosing cholangitis or primary biliary cholangitis, a liver transplant may be the only curative treatment option available.

Prognosis

The prognosis of acute cholangitis depends critically on the speed of treatment. When treated early, outcomes are generally good. However, severe cases involving sepsis can be life-threatening. Chronic forms such as PSC and PBC can lead to liver cirrhosis over many years and require long-term medical management.

References

European Association for the Study of the Liver (EASL): EASL Clinical Practice Guidelines on Cholestatic Liver Diseases. Journal of Hepatology, 2022.
Kiriyama S. et al.: Tokyo Guidelines 2018: Diagnostic criteria and severity grading of acute cholangitis. Journal of Hepatobiliary Pancreatic Sciences, 2018.
Longo DL et al.: Harrison's Principles of Internal Medicine, 21st Edition. McGraw-Hill Education, 2022.

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