This document discusses acute cholangitis, an infection of the biliary tree often caused by enteric bacteria due to biliary stasis or obstruction, with specific diagnostic criteria and severity assessments based on recent guidelines. It highlights the various etiologies including gallstones, obstructive tumors, and procedural complications, along with recommended diagnostic tests such as ultrasound and MRI. Treatment strategies emphasize supportive care and timely biliary drainage, with the prognosis improving due to advancements in management practices.

1. Acute Cholangitis
Diagnostic Criteria & Severity Assessment
Dr Monkez M Yousif MD, AGAF
Professor of Internal Medicine
Zagazig University
2023

2. Definition
 Inflammation of the biliary tree
 This inflammation is more commonly caused by
enteric bacteria in the instance of biliary stasis or
obstruction

3. Epidemiology
 Acute cholangitis is not uncommon
• Occurs in patients with gallstones (0.3-1.6%)
• 12% of these cases fit the Tokyo guidelines for severe disease
 Median age of presentation is between 50-60 y

4. Etiology

5. Etiology - Choledocolithiasis
 Gallstones lodged in the CBD are the most common cause
o They obstruct the flow of bile
o This stasis of bile permits the ascent of enteric bacteria via Ampulla of Vater
from the duodenum resulting in inflammation
o Elevated pressure in the CBD may also result in infection spreading to the
bloodstream via the bile canaliculi, hepatic veins, and perihepatic lymphatics
leading to bacteremia

6. Etiology - ERCP
 ERCP can cause cholangitis where endoscopes and accessories introduce infection
into the biliary tree if not adequately sterilized
 Risk factors for ERCP infection include:
o Incomplete drainage of the biliary tree
o Presence of jaundice
o Placement of a stent in malignant bile duct strictures (such as those caused by pancreatic cancer)

7. Etiology – Obstructive tumors
Carcinoma of head of pancreas causing
narrowing of CBD

8. Etiology – Obstructive tumors
 Choloangiocarcinoma – these most commonly present in the
seventh decade of life
 The position of these tumors can vary
 There are 3 main classifications based on the site of these tumors
― Intrahepatic tumors of the left and right hepatic ducts
― Extrahepatic tumors
o Hilar (occur near the junction of Rt and Lt hepatic ducts
o Distal (can present from the ampulla of Vater upwards)

9. Etiology – Obstructive tumors
 Porta hepatis mass
― The porta hepatis is a groove on the inferior surface of the
liver where various structures pass-through
― A wide array of conditions can cause a mass to develop at
this point, impeding bile flow
― This could include for example,
o thrombosis,
o stenosis or aneurysm of the portal triad vessels, or
o even a rare mass from nerves that pass through a
neurofibrosarcoma

10. Etiology – Benign Bile Strictures
 The majority of these strictures (80%) are iatrogenic,
caused by procedures such as ERCP
 Other causes of benign biliary strictures include:
― Primary sclerosing cholangitis
― Pancreatitis

11. Etiology – Malignant Bile Strictures
 Malignant bile strictures are strictures secondary to malignancy:
― Choloangiocarcinoma
― Pancreatic carcinoma
― Ampullary carcinoma
― Hepatocellular carcinoma
― Lymphoma
― Metastasis

12. Etiology – Mirizzi Syndrome
 This is where the CBD is obstructed by
a large gallstone in the cystic duct

13. Pathogenesis
 Normally, there are different defensive mechanisms to prevent cholangitis.
1. The bile salts have bacteriostatic activity
2. The biliary epithelium secretes IgA and mucous which probably act as anti-adherent
factors.
3. Kupffer cells on the biliary epithelium and the tight junction between the
cholangiocytes prevent translocation of bacteria from the hepatobiliary system into the
portal venous system.
4. Normal bile flow flushes out any bacteria into the duodenum.
5. The sphincter of Oddi also prevents any migration of bacteria from the duodenum into
the biliary system.

14. Pathogenesis
 Biliary obstruction → Bile stasis in the biliary system → ↑ intraductal pressure →
― Widening of the tight junction between cholangiocytes
― Malfunction of Kupffer cells
― Decreased IgA secretion
― cholangiovenous and cholangiolymphatic reflux leading to bacteremia and endotoxemia
― Systemic release of inflammatory mediators like: TNF, IL- 1,6, 10 leading to hemodynamic
instability

15. Diagnosis

16. Jean-Martin Charcot
1877

17. Reynolds BM, Dargan EL (August 1959). "Acute obstructive cholangitis; a distinct clinical
syndrome". Ann Surg. 150 (2): 299–303.

18. Lab workup
 Initial blood tests include:
• CBC, CRP, PT, LFTs, KFTs
 Specifically for diagnostic criteria purposes:
• Inflammation
• WBC < 4k or > 10K or
• CRP ≥ 10 mg/L
• Jaundice
• T Bill ≥ 2
• Abnormal liver chemistries
• ALP > 1.5 × ULN AST > 1.5 × ULN
• GGT > 1.5 × ULN ALT > 1.5 × ULN

19. Imaging
 Ultrasound
• Typically, the initial test performance due to accessibility and the noninvasive nature
• Can evaluate for bile duct dilatation and bile duct stones with high specificity (94-100%), but
varying sensitivity (38-91%)
 Abdominal CT scan
• High sensitivity for bile duct dilatation and biliary stenosis
• High radiation
 MRI/MRCP
• Imaging of choice when indeterminate CT or US findings
• Highly specific (98%) and sensitive (100%) for evaluation of biliary duct dilatation

20. Endoscopic Ultrasound (EUS)
• Best imaging test
• Only takes 5 minutes
• Can perform ERCP at the
same time
• Invasive

21. Diagnostic criteria for AC adapted from TG18/13
A. Systemic inflammation B. Cholestasis C. Imaging
A-1. Fever and/or shaking chills
(T >38°C)
B-1. Jaundice.
o T. bilirubin ≥2 mg/dl
C-1. Biliary dilatation
A-2. Evidence of inflammatory
response.
oWBC <4 k or >10 k/mm3
,
oCRP>/10mg/L
B-2. Abnormal LFTs
o ALP (>1.5 × ULN)
o GGT (>1.5 × ULN)
o AST (>1.5 × ULN)
o ALT (>1.5 × ULN)
C-2. Evidence of etiology on
imaging
o stricture,
o stone,
o stent, and others
Suspected diagnosis: one item in A + one item in either B or C; Definite diagnosis: one item in A, one item in B + one item in C
Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):17-30.
Note: Other factors which are helpful in diagnosis of acute cholangitis include abdominal pain (right upper quadrant or upper abdominal) and a history of
biliary disease such as gallstones, previous biliary procedures, and placement of a biliary stent.

22. Severity assessment criteria for AC adapted from TG18/TG13
Grade Clinical Features Laboratory Findings
I- Mild Does not meet the criteria of
”grade III (severe)” or ”grade
II (moderate)” AC at initial
diagnosis
II- Moderate AC + any 2 of
the following
conditions:
1. Abnormal WBC count (>12k/mm3
or <4k/mm3
)
2. Fever (≥39°C)
3. Age (≥75 years)
4. Hyperbilirubinemia (total bilirubin ≥5 mg/dL )
5. Hypoalbuminemia (< 0.7 x ULN)
III- Severe AC + one
dysfunction at
least in any of the
following systems:
1. Cardiovascular— hypotension requiring vasopressors (dopamine >5
ug/kg per min or any dose of norepinephrine)
2. Neurological — disturbance of consciousness
3. Respiratory — PaO2
/FiO2
<300
4. Renal — oliguria, serum creatinine >2.0 mg/dL
5. Hepatic — INR >1.5
6. Hematologic — platelet count <100k/mm3

23. Differential Diagnosis
 Acute cholecystitis
 Biliary leak
 Acute pancreatitis
 Liver abscess
 Acute hepatitis

24. Triage Disposition
 Mild AC
• Regular floor
• Will need access to endoscopic surfaces for biliary drainage if no response to
treatment within 24 hours or choledocholithiasis suspected
 Moderate AC
• Regular floor or step down
• Will need access to endoscopic surfaces for biliary drainage
 Severe AC
• ICU level care
• Emergent biliary drainage

25. Overall Treatment Approach
 Disease severity may help guide the treatment plan
 Mortality can exceed 50% if cholangitis is not treated
 General management approach
• Supportive treatment and hemodynamic stabilization
• Antibiotic therapy
• Biliary decompression

26. Supportive Therapy
 Volume resuscitation with IV fluids
 Analgesics for pain control
 Antiemetics
 Correction of electrolyte disturbances
 Treatment of end-organ dysfunction
• Pressors for septic shock
• Intubation for respiratory support
 NPO for potential biliary drainage procedures
 Discontinuation and reversal of anticoagulation

27. Antibiotic Therapy
 Antibiotic selection should target the most common intra-
abdominal bacteria
 Initial choice can be piperacillin-tazobactam, cephalosporin plus
metronidazole, or ampicillin-sulbactam depending on severity
 Tailor antibiotic selection to culture and susceptibility results
 Duration of antibiotic treatment is usually 7 days after source
control is achieved and longer if bacteremia is present

28. Isolated microorganisms from
bile cultures
Proportions of isolated
organisms (%)
Gram-negative organisms
o Escherichia coli
o Klebsiella spp.
o Pseudomonas spp.
o Enterobacter spp.
Gram-positive organisms
o Enterococcus spp.
o Streptococcus spp.
o Staphylococcus spp.
Anaerobes
31–44
9–20
0.5–19
5–9
3–34
2–10
0 in bile but 3.6 in blood
culture
4–20
Common microorganisms
isolated from bile cultures
among patients with acute
biliary infections
(endorsed from the TG13)

29. Endoscopic Intervention
 ERCP is the primary modality of choice
• Stone Extraction
• Endoscopic drainage with or without biliary
stent

30. Percutaneous Transhepatic Biliary
Drainage
o Performed when endoscopic
drainage is unavailable,
unsuccessful, or the patient is too
unstable for anesthesia
o Can be done by IR via intrahepatic
approach into the bile duct

31. Alternative Intervention
 EUS-guided biliary drainage
• in patients with moderate-severe cholangitis
 Surgical Drainage
• Rarely used, when all other methods of source control
have failed

32. Timing of Endoscopic Intervention
 Early biliary drainage via ERCP within 24 h has been
associated with decreased hospital stay and recurrent
cholangitis, though no significant difference in mortality if
done within 72 h

33. Prognosis
 Early studies from the 1970s show mortality rates exceeding 50%
 More recent studies show mortality rates of 11% or less for mild
to moderate disease
 Severe disease carries a mortality rate between 20-30%

34. Flowchart for the initial response to acute biliary infection

36. Take-Home Messages
 AC is an infection of the biliary tree
 Diagnosis is based on evidence of systemic inflammation, cholestasis, and
imaging findings of biliary obstruction
 Mainstays of treatment are end-organ support, IV antibiotics, and biliary
decompression
 Disease severity can be mild, moderate, or severe, which can help inform the
disposition and timing of biliary drainage
 Mortality rates are decreasing with improvements in patient care and biliary
drainage techniques

37. Monkez Yousif