Ascending Cholangitis Clinical Overview
I. The "On-Call" Snapshot
Clinical Significance in Malaysia: This is a life-threatening biliary emergency you will see in ED and on surgical calls. Missing this leads to septic shock and high mortality. It's a common complication of untreated gallstone disease, which is prevalent here.
High-Yield Definition: Ascending cholangitis is an infection of the biliary tree secondary to biliary obstruction, leading to systemic inflammation and, potentially, severe sepsis.
Clinical One-Liner: Basically, it's a bacterial infection of the bile ducts because something, usually a stone, is blocking the flow of bile.
II. Etiology & Risk Factors
Etiology:
Choledocholithiasis (CBD Stones): The cause in >80% of cases.
Benign Biliary Strictures: Often post-surgical or post-ERCP.
Malignancy: Pancreatic head tumour, cholangiocarcinoma, or ampullary cancer causing external compression or obstruction.
Instrumentation: Post-ERCP or PTBD.
Risk Factors:
Modifiable: Recent biliary instrumentation (ERCP).
Non-Modifiable: Known gallstone disease, previous biliary surgery, congenital abnormalities (e.g., Caroli's disease), increasing age.
III. Quick Pathophysiology
Biliary obstruction is the key event. It causes bile stasis and raises intraductal pressure. This allows bacteria that normally ascend from the duodenum in small, insignificant numbers to proliferate. The high pressure disrupts the protective barrier of the bile duct lining, forcing bacteria and their endotoxins directly into the bloodstream (bacteremia), which triggers a systemic inflammatory response and sepsis.
IV. Clinical Assessment
Red Flags & Immediate Actions:
Hypotension (SBP <90 mmHg): Alert senior immediately, secure second large-bore IV access, start aggressive fluid bolus (e.g., 500ml Hartmann's stat).
Altered Mental Status (new confusion, GCS <15): This is Reynolds' Pentad. It signifies severe sepsis with end-organ dysfunction. Action: Alert senior and consider ICU referral.
Oliguria / Anuria: Insert urinary catheter to monitor output. This is a sign of acute kidney injury (AKI) from shock.
History:
Charcot's Triad (Present in 50-70%):
Fever with rigors
Right Upper Quadrant (RUQ) pain
Jaundice
Pertinent Negatives: Ask about pain radiating to the back (pancreatitis), weight loss or change in bowel habits (malignancy).
Physical Examination:
General: Check for scleral icterus. Assess for signs of shock (tachycardia, hypotension, cool peripheries, prolonged CRT).
Abdomen: Palpate for RUQ tenderness. Note that Murphy's sign is typically negative unless there is concurrent acute cholecystitis.
Clinical Pearl: Don't wait for the full triad to develop. Any patient with known gallstones who presents with fever and a cholestatic liver function test (LFT) pattern should be considered to have cholangitis until proven otherwise.
V. Diagnostic Workflow
Differential Diagnosis:
Acute Cholecystitis:
Points For: Fever, RUQ pain.
Points Against: Jaundice is uncommon.
How to Differentiate: Ultrasound will show gallbladder wall thickening and a positive sonographic Murphy's sign, with a non-dilated CBD.
Acute Pancreatitis (Gallstone-induced):
Points For: Abdominal pain, may have deranged LFTs.
Points Against: Pain is typically epigastric and radiates to the back.
How to Differentiate: Serum amylase or lipase will be >3 times the upper limit of normal.
Liver Abscess:
Points For: High-grade fever, RUQ pain.
Points Against: Jaundice is less common.
How to Differentiate: Ultrasound or CT scan will show a rim-enhancing collection within the liver parenchyma.
Investigations Plan:
Bedside / Initial (First 15 Mins):
IV Access x2: Send bloods: FBC, RP, LFT, CRP, Coagulation Screen, Blood C&S x2, GXM.
ECG: Rule out cardiac causes of pain.
VBG/ABG: Check lactate as a marker of shock.
First-Line Labs & Imaging:
Bloods: Expect neutrophilic leukocytosis (high WCC), cholestatic picture on LFT (markedly raised ALP and GGT, raised bilirubin), and high CRP.
Ultrasound Abdomen: This is the initial imaging of choice. Look for Common Bile Duct (CBD) dilation (>6-8mm) and the presence of stones (choledocholithiasis).
Confirmatory / Gold Standard:
MRCP (Magnetic Resonance Cholangiopancreatography): The non-invasive gold standard for visualising the biliary tree to confirm the presence, level, and cause of obstruction.
ERCP (Endoscopic Retrograde Cholangiopancreatography): This is the definitive investigation as it is both diagnostic and therapeutic.
VI. Staging & Severity Assessment
We use the Tokyo Guidelines 2018 (TG18) to diagnose and grade severity.
Diagnosis:
A. Systemic Inflammation: Fever and/or rigors, high WCC or CRP.
B. Cholestasis: Jaundice (Bilirubin >34 µmol/L), abnormal LFTs.
C. Imaging: Biliary dilation on imaging or evidence of a cause (stone, stricture).
Definite Diagnosis: One item from A + one from B + one from C.
Severity Grading:
Grade III (Severe): Evidence of organ dysfunction (e.g., hypotension requiring vasopressors, altered consciousness, AKI, thrombocytopenia). Requires IMMEDIATE biliary drainage (<12 hours).
Grade II (Moderate): Meets two of the following: WCC >12k, Temp >39°C, Age >75, High Bilirubin, Low Albumin. Requires EARLY biliary drainage (<48-72 hours).
Grade I (Mild): Does not meet the criteria for Grade II or III. Responds to initial medical treatment. Plan for elective drainage later.
VII. Management Plan
Immediate Stabilisation (The ABCDE Plan):
Airway/Breathing: High-flow oxygen via face mask (10-15L/min) to maintain SpO2 >94%.
Circulation: Aggressive IV fluid resuscitation with crystalloids (Hartmann's or Normal Saline). If hypotensive, give a 500ml bolus and reassess.
Disability: Monitor GCS. Correct hypoglycemia if present.
Exposure: Keep NBM (Nil By Mouth). Start broad-spectrum IV antibiotics after taking blood cultures. A common local regimen is IV Piperacillin/Tazobactam (Tazocin) 4.5g TDS. Refer to your hospital's antibiotic guidelines.
Insert a urinary catheter to monitor urine output.
Definitive Treatment (Biliary Decompression):
First-Line: ERCP with sphincterotomy. The endoscopist will remove the stones or place a stent to relieve the obstruction.
Second-Line: PTBD (Percutaneous Transhepatic Biliary Drainage). Performed by Interventional Radiology. Used if ERCP fails or is anatomically impossible.
Third-Line: Surgical Decompression. Rarely done acutely. Laparoscopic or open exploration of the CBD with T-tube placement.
Long-Term & Discharge Plan:
The underlying cause must be treated. If due to gallstones, the patient must be counselled for and scheduled for an elective laparoscopic cholecystectomy to prevent recurrence.
VIII. Complications
Immediate: Septic shock, multi-organ dysfunction syndrome (MODS), death.
Short-Term: Post-ERCP pancreatitis, bleeding, duodenal perforation.
Long-Term: Recurrent cholangitis, secondary biliary cirrhosis (if obstruction is chronic), biliary strictures.
IX. Prognosis
Mortality is directly related to the severity and timeliness of intervention.
Grade I (Mild): Mortality is very low (<1%).
Grade III (Severe) / Reynolds' Pentad: Mortality can be as high as 10-20%, even with modern treatment.
Key Prognostic Factors: Presence of organ failure, delay to biliary decompression, and underlying comorbidities.
X. How to Present to Your Senior
"Dr., for review please. This is Mdm. Chan in Bed 10, a 68-year-old lady with a known history of gallstones, who presented with fever, RUQ pain, and jaundice. On examination, she is confused, tachycardic at 110, and hypotensive at 88/50. My main differential is Severe Ascending Cholangitis (Grade III) with septic shock. I have already started IV fluids, taken blood cultures, and given the first dose of IV Tazocin. I think she needs urgent biliary drainage and may need ICU support."
XI. Summary & Further Reading
Top 3 Takeaways:
Recognize Charcot's triad and Reynolds' pentad. Suspect cholangitis in any septic patient with a cholestatic LFT.
Management is simple: resuscitate, give antibiotics, and arrange for biliary drainage.
Use the TG18 guidelines to grade severity, as this dictates the urgency of drainage.
Key Resources:
Guidelines: Tokyo Guidelines 2018: Diagnostic criteria and severity grading of acute cholangitis (TG18)
UpToDate: "Acute cholangitis: Pathogenesis, clinical manifestations, and diagnosis"
Amboss: "Ascending Cholangitis"
