Etiology

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Microbiology

• General Comments
  • Mixed Infections are Common
  • The Most Commonly-Isolated Organisms Originate from the Colon
• Bacteroides (see Bacteroides)
  • Epidemiology: usually present as part of a mixed infection
• Clostridium (see Clostridium)
  • Epidemiology: usually present as part of a mixed infection
• Enterobacter (see Enterobacter)
• Escherichia Coli (see Escherichia Coli)
  • Epidemiology: most common Gram-negative pathogen
• Enterococcus (see Enterococcus)
  • Epidemiology: most common Gram-positive pathogen
• Klebsiella (see Klebsiella)
  • Epidemiology: second most Gram-negative common pathogen
• Serratia Rubidaea (see Serratia Rubidaea)

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Diagnosis

Complete Blood Count (CBC) (see Complete Blood Count)

• Leukocytosis (see Leukocytosis)

Liver Function Tests (LFT’s) (see Liver Function Tests)

• Cholestatic Pattern (see Elevated Liver Function Tests)
  • Elevated Alkaline Phosphatase
    • Threshold Level for Alkaline Phosphatase in Acute Cholangitis: 450 IU/L (Hepatogastroenterology, 2014) [MEDLINE]
  • Hyperbilirubinemia (see Hyperbilirubinemia, [[Hyperbilirubinemia]]): predominantly conjugated bilirubin
  • Elevated Gamma-Glutamyl Transpeptidase (GGT)
    • Threshold Level for GGT in Acute Cholangitis: 100 IU/L (Hepatogastroenterology, 2014) [MEDLINE]
• Acute Hepatic Necrosis Pattern: less common (but has been reported in cases with hepatic microabscess formation with associated hepatic necrosis)
  • Transaminitis: : may be as high as 2000 IU/L in some cases (Med Clin North Am, 2008) [MEDLINE]

Blood Culture (see Blood Culture)

• Recommended

Abdominal Ultrasound (see Abdominal-Pelvic Ultrasound)

• Findings
  • Biliary Dilation
  • Biliary Stone: may be present
  • Biliary Stent: may be present in relevant cases
  • Biliary Stricture: may be present
• Sensitivity/Specificity
  • May Be Negative Some Cases: particularly when only small biliary stones are present or when biliary system is acutely obstructed (with inadequate time to dilate)

Abdominal CT (see Abdominal-Pelvic Computed Tomography)

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Endoscopic Retrograde Cholangiopancreatography (ERCP) (see Endoscopic Retrograde Cholangiopancreatography)

• Procedure of Choice
  • Allows for Confirmation of Diagnosis
  • Allows Operator to Obtain Material for Culture
    • Culture of Bile, Ductal Stones, and/or Biliary Stents are Positive in >90% of Cases
  • Allows for Biliary Drainage

Magnetic Resonance Cholangiopancreatography (MRCP) (see Magnetic Resonance Cholangiopancreatography)

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Clinical Manifestations

General Comments

• Charcot’s Triad: classical triad is present in only 50-75% of cases
  • Abdominal Pain (see Abdominal Pain)
  • Fever (see Fever)
  • Jaundice (see Jaundice)
• Reynold’s Pentad
  • Altered Mental Status (see Altered Mental Status)
    • Confusion/Delirium (see Delirium)
  • Abdominal Pain (see Abdominal Pain)
  • Fever (see Fever)
  • Jaundice (see Jaundice)
  • Hypotension/Shock (see Hypotension and Sepsis)

Gastrointestinal Manifestations

• Jaundice/Hyperbilirubinemia (see Jaundice and Hyperbilirubinemia)
• RUQ Abdominal Pain (see Abdominal Pain)

Infectious Manifestations

• Fever (see Fever)
• Sepsis (see Sepsis)

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Treatment

Antibiotics

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Endoscopic Retrograde Cholangiopancreatography (ERCP) (see Endoscopic Retrograde Cholangiopancreatography)

• Allows for Biliary Drainage

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References

Microbiology

• Serratia rubidaea as an invasive pathogen. J Clin Microbiol. 1996 Jan;34(1):216-7 [MEDLINE]

Diagnosis

• Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis. Med Clin North Am. 2008 Jul;92(4):925-60 [MEDLINE]
• An association of elevated levels of alkaline phosphatase and gamma-glutamyl transpeptidase with acute cholangitis. Hepatogastroenterology. 2014 Mar-Apr;61(130):291-5 [MEDLINE]

Treatment

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