Cholangitis

What is Cholangitis?

Cholangitis is swelling and inflammation of bile duct often associated with bacterial infection. The infection leading to cholangitis may be abrupt or chronic.

The bile duct system helps in carrying bile produced in the liver and stored in the gallbladder and takes it to the small intestines where it performs it’s function. If there is an infection in the bile duct, it may cause it to swell and inflame. ^1,2,3,4,5

Causes

There are many causes of cholangitis and the most common one is obstruction or blockage occurring within the bile duct system. When there is blockage, the bile may not drain properly and an infection may arise. The blockage may be due to something like blood clots, tumors, stones, or narrowing of the ducts after a surgical procedure.

The blockage may also be caused by something like parasite invasion and swelling of pancreas. It may also occur due to inflammation of liver or bile ducts. Other causes of cholangitis include:

• Backflow of bacteria microbes from the small intestine
• Complications of a diagnostic procedure like an endoscopic examination that transfers bacteria to the body. Endoscopic examination is a test that is conducted to check gallbladder and liver.
• Blood infection or bacteriemia

Symptoms

An individual having cholangitis may show symptoms, which may range from medium to severe. The symptoms may vary from a person to another. Here are some of the symptoms likely to be experienced by a person with cholangitis:

• Chills
• Dark urine
• Lethargy
• Pain occurring within the upper right side of the belly or abdomen
• Fever
• Nausea and vomiting
• Low blood pressure
• Not being alert
• Yellowing of eyes and skin, something known as jaundice
• Clay-colored stool.

Diagnosis

Since cholangitis symptoms may resemble those of other diseases, it is important that you get the right diagnosis. The pain arising from cholangitis may feel like pain related to gallstones. A doctor may perform a series of diagnosis procedures to help identify the cause.

Physical exam & history

The doctor may perform physical examination and ask questions regarding your past medical history.

Blood tests

A doctor may order blood tests such as complete blood count (CBC). If you are having an infection, which is causing cholangitis, your white blood cell count could be high. A liver function test may be conducted to help determine if the organ is working properly. Blood cultures can also help detect a blood infection.

Imaging tests

Some of the imaging tests conducted to help diagnose a patient of cholangitis include:

PTC

With this Percutaneous transhepatic cholangiography, a needle is taken through the skin to reach the liver. During the procedure, dye is put into a patient’s bile duct to allow the doctor to see the bile ducts clearly on X-ray images.

ERCP

With this Endoscopic retrograde cholangiopancreatography, it is used to establish if there is a problem with the gallbladder, liver, pancreas, and bile ducts. ERCP uses X-ray along with a long flexible tube consisting of a light and camera fitted on one end. This is called the endoscope.

Usually, the tube is put into a patient’s mouth and throat. The tube goes down through the food pipe or esophagus, then through the stomach, before it reaches the duodenum, which is the first part of the small intestine.

In the procedure, a dye is also put into bile ducts using the tube and that dye helps see the bile ducts clearly on X-rays.

MRCP

Using Magnetic resonance cholangiopancreatography, a doctor checks for problems with the abdomen. This imaging test can help show if the bile ducts are blocked by gallstones. Usually, this test is performed from outside of the patient’s body. This means that the procedure does not involve use of a tube or endoscope. Instead, radio frequency and magnetic fields are used to make detailed pictures.

CT scan

A doctor may perform a CT scan with a dye injected through an IV or swallowed. The test shows the pelvis and abdomen as well as the bile drainage area. CT scan can help determine why an obstruction or blockage is happening.

Ultrasound (Sonography)

this imaging device, a doctor creates images showing the internal organs on a PC screen with use of high frequency sound waves. Ultrasound technique can help see organs within the belly including spleen, liver, and gallbladder. The test also checks for a patient’s blood flow in vessels.

Ultrasound may be performed outside the body meaning external procedure or it could also be done inside the body meaning internal procedure. When it is internal, the procedure is referred to as endoscopic ultrasound or EUS.

Treatment

When you are diagnosed with cholangitis, a doctor will use different treatment options to help address the problem.

Fluids and antibiotics

A patient may need to be hospitalized for a couple of days and during that time, they are given fluids by IV line via a vein. Pain medications may be given as well as antibiotics to help fight a bacterial infection. Antibiotics used to treat the patient may include:

• A combination of aminoglycosides and penicillins
• Ciprofloxacin – This has shown to be quite effective in treating most cases of cholangitis arising from bacterial infection
• Metronidazole may be added in the treatment to help in treating anaerobic pathogens, particularly in patients that are very ill or those at risk of having anaerobic infections.

Blood pressure medications

Drugs used to increase a patient’s blood pressure may be used to help counter incidents of low blood pressure. These drugs include vasopressors.

Endoscopy

This may be used if a patient does not show improvement despite using antibiotics. The aim of this treatment option is to help relief the causal biliary obstruction or the underlying obstruction of biliary.

However, this procedure is deferred for some time to see if a patient responds to more lenient treatment options such as use of drugs. It is done after 24 to 48 hours following the admission of the patient.

ERCP or Endoscopic retrograde cholangiopancreatography is believed to be the commonest approach used to unblock the bile ducts. In this treatment option, an endoscope or fiberoptic tube is taken through the patient’s stomach to reach the duodenum.

A sphincterotomy is performed to help ease the flowing of bile juice from the duct so that it makes it easy for insertion of instruments being used to extract gallstones, which may be obstructing the bile duct.

A balloon may also be used to dilate the bile duct and help remove the gallstones. The stones could be removed by use of instructions or direct suction. If the gallstones are bigger, they may be crushed using an instrument called mechanical lithotripter. The crushing allows the stones to be easily removed.

Use of stents

If the bile ducts are narrowed by something like a tumor, permanent stents that are self expanding metals are used because they have a longer lifespan.

Surgery

If a patient does not respond to other conventional methods of treatment such as use of antibiotics and non-invasive procedures such as ERCP, then surgery may be opted.

Reference List

1. Cholangitis. https://patient.info/doctor/cholangitis
2. http://ddc.musc.edu/public/diseases/pancreas-biliary-system/cholangitis.html
3. Ascending cholangitis.https://en.wikipedia.org/wiki/Ascending_cholangitis
4. Cholangitis http://www.hopkinsmedicine.org/healthlibrary/conditions/liver_biliary_and_pancreatic_disorders/cholangitis_85,P00660/
5. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=85&contentid=P00660