Key Points

• Acute severe cholangitis (ACST) is a life-threatening infection of the biliary tract due to obstruction and bacterial invasion.
• Presents with Charcot’s triad (fever, right upper quadrant pain, jaundice) and may progress to Reynolds’ pentad (hypotension, confusion) in severe cases.
• Classified by Tokyo Guidelines into mild, moderate, and severe based on organ dysfunction and inflammatory markers.
• Urgent management includes hemodynamic resuscitation, broad-spectrum antibiotics, and early biliary decompression (ERCP, PTBD, or surgery).
• Delayed source control increases the risk of sepsis, multi-organ failure, and mortality.

Introduction

Acute cholangitis arises from biliary stasis and bacterial infection. When untreated or severe, it leads to systemic inflammatory response and sepsis, known as acute severe cholangitis (ACST). Prompt diagnosis and intervention are critical to reduce morbidity and mortality.

Epidemiology

• Incidence: Varies globally; higher in regions with gallstone disease and biliary tract interventions.
• Age: Most common in older adults (50–70 years).
• Gender: Slight female predominance due to higher gallstone prevalence.

Etiology and Pathogenesis

• Obstruction of bile flow by gallstones, strictures (benign or malignant), parasites (Ascaris, Clonorchis), or instrumentation.
• Bacterial invasion from intestinal flora (Escherichia coli, Klebsiella, Enterococcus) into static bile.
• Elevated intraductal pressure and impaired mucosal barrier allow endotoxin absorption, cytokine release (TNF-α, IL-6), and systemic inflammation.
• Hyperbilirubinemia and cholestatic liver injury result from ductal epithelial damage and reflux of bile into the bloodstream.

Clinical Presentation

Charcot’s Triad

• Fever and chills
• Right upper quadrant (RUQ) pain
• Jaundice

Reynolds’ Pentad (Severe Disease)

• Hypotension (systolic <100 mmHg)
• Altered mental status (confusion, lethargy)

Classification (Tokyo Guidelines 2018)

• Grade I (Mild): No organ dysfunction; responds to medical treatment.
• Grade II (Moderate): Two or more of the following: WBC >12,000/mm³, fever ≥39°C, age ≥75 years, bilirubin ≥5 mg/dL, hypoalbuminemia.
• Grade III (Severe): Dysfunction in any one organ/system (cardiovascular, neurologic, respiratory, renal, hepatic, hematologic).

Diagnostic Evaluation

Laboratory Studies

• CBC: leukocytosis
• Liver function tests: cholestatic pattern (ALP, GGT, bilirubin)
• Inflammatory markers: elevated CRP, procalcitonin
• Blood cultures: obtain prior to antibiotics

Imaging

• Ultrasound: first-line; dilated bile ducts, stones.
• Contrast-enhanced CT: assess biliary obstruction, abscesses, pancreatitis.
• MRCP: noninvasive biliary anatomy evaluation.
• Endoscopic ultrasonography (EUS): detect small stones or lesions.

Management

Initial Resuscitation

• Airway support, IV fluids, oxygen, vasopressors for hypotension.
• Broad-spectrum IV antibiotics covering gram-negative, gram-positive, and anaerobes (e.g., piperacillin–tazobactam, cefepime + metronidazole).

Biliary Decompression (Urgent within 24–48 hours)

• ERCP with sphincterotomy and stone extraction or stenting: gold standard for bile drainage.
• Percutaneous transhepatic biliary drainage (PTBD): alternative when ERCP is not feasible or fails.
• Surgical drainage: reserved for complex cases or failed endoscopic/radiologic approaches.

Antibiotic Stewardship

• De-escalate therapy based on culture sensitivities.
• Typical duration: 7–10 days after source control; shorter courses in mild disease.

Nursing Considerations

• Monitor vital signs, intake/output, mental status, and abdominal exam.
• Ensure timely administration of antibiotics and fluids.
• Prepare patient for ERCP/PTBD: consent, NPO status, sedation planning.
• Post-procedure care: monitor for bleeding, perforation, cholangitis recurrence.

Complications and Prognosis

• Septic shock, acute kidney injury, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC).
• Mortality: 10–30% in severe cholangitis; reduced with early drainage and sepsis management.

Patient Education

• Recognize early symptoms: fever, RUQ pain, jaundice.
• Importance of prompt medical attention and adherence to follow-up.
• Lifestyle modifications: manage gallstone risk factors (diet, weight control).

References

1. Kiriyama S, Takada T, Strasberg SM, et al. TG18 guidelines for diagnosis and severity grading of acute cholangitis. J Hepatobiliary Pancreat Sci. 2018;25(1):17–30.
2. Sartelli M, Catena F, Ansaloni L, et al. The management of acute cholangitis: Recommendation from WSES Guidelines. World J Emerg Surg. 2011;6:31.
3. Solomkin JS, Mazuski JE, Bradley JS, et al. 2010 SIS/IDSA guidelines for complicated intra-abdominal infection. Clin Infect Dis. 2010;50(2):133–164.
4. Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010;71(3):446–454.