7/10/2015

AcuteCholangitisClinicalPresentation:History,Physical,Causes

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

History
In1877,Charcotdescribedcholangitisasatriadoffindingsofrightupperquadrant(RUQ)pain,fever,andjaundice.
TheReynoldspentadaddsmentalstatuschangesandsepsistothetriad.Aspectrumofcholangitisexists,ranging
frommildsymptomstofulminantoverwhelmingsepsis.Withsepticshock,thediagnosiscanbemissedinupto
25%ofpatients.Considercholangitisinanypatientwhoappearsseptic,especiallyinpatientswhoareelderly,
jaundiced,orwhohaveabdominalpain.Ahistoryofabdominalpainorsymptomsofgallbladdercolicmaybeaclue
tothediagnosis.
Symptomsincludethefollowing:
Charcot'striadconsistsoffever,RUQpain,andjaundice.Itisreportedinupto5070%ofpatientswith
cholangitis.However,recentstudiesbelieveitismorelikelytobepresentin1520%ofpatients.
Feverispresentinapproximately90%ofcases.
Abdominalpainandjaundiceisthoughttooccurin70%and60%ofpatients,respectively.
Patientspresentwithalteredmentalstatus1020%ofthetimeandhypotensionapproximately30%ofthe
time.Thesesigns,combinedwithCharcot'striad,constituteReynoldspentad.
Consequently,manypatientswithascendingcholangitisdonotpresentwiththeclassicsignsandsymptoms.
[5]

MostpatientscomplainofRUQpainhowever,somepatients(ie,elderlypersons)aretooilltolocalizethe
sourceofinfection.
Othersymptomsincludethefollowing:
Jaundice
Fever,chills,andrigors
Abdominalpain
Pruritus
Acholicorhypocholicstools
Malaise
Thepatient'smedicalhistorymaybehelpful.Forexample,ahistoryofthefollowingincreasestheriskof
cholangitis:
Gallstones,CBDstones
Recentcholecystectomy
EndoscopicmanipulationorERCP,cholangiogram
Historyofcholangitis
HistoryofHIVorAIDS:AIDSrelatedcholangitisischaracterizedbyextrahepaticbiliaryedema,ulceration,
andobstruction.Theetiologyisuncertain,butitmayberelatedtocytomegalovirusorCryptosporidium
infections.Themanagementofthisconditionisdescribedbelow,althoughdecompressionisusuallynot
necessary.

Physical
Ingeneral,patientswithcholangitisarequiteillandfrequentlypresentinsepticshockwithoutanapparentsourceof
theinfection.
Physicalexaminationmayrevealthefollowing:
Fever(90%),althoughelderlypatientsmayhavenofever
RUQtenderness(65%)
Mildhepatomegaly
Jaundice(60%)
Mentalstatuschanges(1020%)
Sepsis
Hypotension(30%)
Tachycardia
Peritonitis(uncommon,andshouldleadtoasearchforanalternativediagnosis)

Causes
InWesterncountries,choledocholithiasisisthemostcommoncauseofacutecholangitis,followedbyERCPand
tumors.
AnyconditionthatleadstostasisorobstructionofbileintheCBD,includingbenignormalignantstricture,parasitic
infection,orextrinsiccompressionbythepancreas,canresultinbacterialinfectionandcholangitis.Partial
obstructionisassociatedwithahigherrateofinfectionthancompleteobstruction.

Commonbileductstones
CBDstonespredisposepatientstocholangitis.Approximately1015%ofpatientswithcholecystitishaveCBD
stones.
Approximately1%ofpatientspostcholecystectomyhaveretainedCBDstones.MostCBDstonesareimmediately
symptomatic,whilesomeremainasymptomaticforyears.
SomeCBDstonesareformedprimarilyratherthansecondarilytogallstones.

Obstructivetumors
Obstructivetumorscausecholangitis.Partialobstructionisassociatedwithanincreasedrateofinfectioncompared

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

1/3

7/10/2015

AcuteCholangitisClinicalPresentation:History,Physical,Causes

withthatofcompleteneoplasticobstruction.Obstructivetumorsincludethefollowing:
Pancreaticcancer
Cholangiocarcinoma[6]
Ampullarycancer
Portahepatistumorsormetastasis

Othercauses
Additionalcausesofcholangitisincludethefollowing:
Stricturesorstenosis
EndoscopicmanipulationoftheCBD
Choledochocele
Sclerosingcholangitis(frombiliarysclerosis)
AIDScholangiopathy
Ascarislumbricoidesinfections

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
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

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

2/3

7/10/2015

AcuteCholangitisClinicalPresentation:History,Physical,Causes

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/774245clinical#showall

3/3