Acute Cholangitis: An Update in Management Based on Severity Assessment

Robert Christeven,Frandy Frandy,Andersen Andersen

doi:10.24871/1932018170-177

Abstract

Acute cholangitis (AC) is a biliary tract emergency which causes significant morbidity and mortality. The direct cause of death in AC is sepsis that leads to irreversible shock and multiple organ failure. The most common predisposition are bile duct stones and previous invasive manipulation of the biliary tree. Biliary infection and biliary obstruction are the two main factors in pathophysiology of AC. Gram-negative bacteria are isolated frequently from bile and blood culture in cholangitis. The most common cause of biliary obstruction is gallstone.The Charcot’s triad which commonly has been used to diagnose AC is severely limited and the clinical presentation of the disease has wide spectrum ranging from mild symptoms to severe life-threatening disease. Thus, the use of the most updated Tokyo Guidelines (TG18) is imperative to diagnose the disease and to assess the severity. The TG18 diagnostic criteria is based on the presence of systemic inflammmation, cholestasis, and evidence on imaging studies of biliary tract. The prompt treatment is tailored according to severity assessed by TG18. Initial treatment includes sufficient fluid replacement, hemodynamic control, electrolyte compensation, intravenous antibiotic administration, and intravenous analgesic administration. The definitive treatment which related to the pathophysiology of the disease are biliary drainage and antibiotic administration.

Highlights

Acute cholangitis (AC) is one of the biliary tract emergencies in the spectrum of acute biliary infection with high morbidity and mortality rates; it needs straightforward diagnostic evaluation and immediate treatment initiation
Clinical presentation of AC ranges from mild symptoms to severe life-threatening with septic shock conducting rapidly to death.2,Q &KDUFRW ¿UVW described the Charcot’s triad – a clinical pattern with intermittent fever accompanied by chills and rigor, right upper abdominal pain and jaundice
Even though new technologies and knowledge are steadily accumulating, there is no way to directly diagnose Acute Cholangitis based on imaging findings.[8]

Summary

INTRODUCTION

Acute cholangitis (AC) is one of the biliary tract emergencies in the spectrum of acute biliary infection with high morbidity and mortality rates; it needs straightforward diagnostic evaluation and immediate treatment initiation. Most cases respond to initial medical treatment consisting of general supportive therapy and intravenous antimicrobial therapy As a therapeutic procedure for severe cases or to prevent increased severity, decompression of the biliary tract (i.e., biliary tract drainage) is necessary.[5] Recent advances in and diffusion of endoscopic biliary tract drainage along with the administration of antimicrobial agents have contributed to the decrease in the number of deaths due to acute cholangitis It remains a life-threatening disease if the timing of biliary tract drainage has been missed.[3,5] immediate and precise judgment of severity is of the utmost importance. Some patients may not manifest all the symptoms and signs

Imaging Findings

Hepatic dysfunction

CONCLUSION