Cholangitis

Cholangitis means inflammation of the bile ducts. It applies to the inflammation of any portion of the bile ducts, which carry bile from the liver to the gallbladder and intestine.

Bile is a bitter yellowish fluid produced by the liver. It is stored in the gallbladder and is released into the intestine to help in digestion, with the primary function of breaking down fats.

Cholangitis is a life-threatening bacterial infection of the biliary tract.

Cholangitis refers to an infection of the bile ducts.

Some circumstances may increase the growth and accumulation of bacteria in the bile ducts:

• Benign obstruction to bile flow, for example, a blockage due to bile duct stones or gallstones in the bile duct (choledocholithiasis).
• Malign obstruction to the bile flow due to bile duct cancer (cholangiocarcinoma) or pancreatic cancer.
• Ascent of germs from the duodenum.

The most common intestinal bacteria associated with infection of the bile ducts are Escherichia coli (25-50% of the cases) followed by Klebsiella (15-20% of the cases) and Enterobacter species (5-10%), although more than one type of bacteria may be present simultaneously.

Another source of inflammation of the bile ducts occurs in autoimmune diseases where the immune system fails to recognize certain cells as part of its normal composition. Primary sclerosing cholangitis is a typical example of an autoimmune disease involving the bile ducts.

The median age of patients with cholangitis is 50-60 years.

The main symptoms of cholangitis are the Charcot triad:

• Fever and chills
• Jaundice (yellow discoloration of the skin and eyes)
• Right upper quadrant abdominal pain

However, the three symptoms at the same time are only present in 50% of the cases.

Other less specific symptoms may be:

• Hypotension
• Nausea
• Vomiting
• Dark urine
• Discolored stools

In some severe cases, shock and altered mental status may occur.

El The initial diagnosis is based on the clinical symptoms. In a blood test, it is common an abnormal elevation of WBCs (leukocytosis), elevated bilirubin (hyperbilirubinemia) and abnormal or elevated tests of liver function (alkaline phosphatase, GGT, lipase, amylase).

The specific bacteria are identified from blood cultures in approximately 70% of the cases.

In addition, imaging tests should be performed to locate a possible obstruction of the bile duct:

• Endoscopic retrograde cholangiopancreatography (ERCP)
• Magnetic resonance cholangiopancreatography (MRCP)
• Endoscopic ultrasound

The recommended treatment consists in:

• Broad-spectrum antibiotics
• Absolute diet
• Intravenous fluids
• Analgesics

Besides, it is necessary to treat the underlying cause of the infection.

In case of obstruction, endoscopic retrograde cholangiopancreatography (ERCP) has the advantage of being able to treat the cause of obstruction, by removing stones and dilating (stretching) structures.

If all the conservative treatments fail, it is necessary a surgical procedure of the bile duct.