Abstract
Bacterial infection that occurs in the setting of biliary obstruction can lead to acute cholangitis, a condition characterized by fever, abdominal pain and jaundice. Choledocholithiasis is the most common cause of acute cholangitis and is often associated with bacterial infection and colonization in addition to biliary obstruction. Iatrogenic introduction of bacteria into the biliary system most commonly occurs during endoscopic retrograde cholangiopancreatography in patients with biliary obstruction. The majority of patients with acute cholangitis respond to antibiotic therapy, but endoscopic biliary drainage is ultimately required to treat the underlying obstruction. Acute cholangitis is often diagnosed using the clinical Charcot triad criteria; however, recommendations from an international consensus meeting in Tokyo produced the most comprehensive recommendations for the diagnosis and management of acute cholangitis. These guidelines enable a more accurate diagnosis of acute cholangitis than do earlier methods, and they facilitate the classification of disease as mild, moderate or severe. Although these guidelines represent a notable advance toward defining a universally accepted consensus for the definition of acute cholangitis, they have several limitations. This Review discusses current recommendations for the diagnosis of acute cholangitis and addresses the advantages and disadvantages of different modalities for the treatment of this disease.
Key Points
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Diagnosis of acute cholangitis has traditionally been made by the Charcot triad criteria; that is, clinical findings of fever, biliary tract pain and jaundice
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Approximately 80% of patients with acute cholangitis respond to broad-spectrum antibiotics alone while the remainder require early biliary drainage in addition to antibiotic therapy
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Endoscopic retrograde cholangiopancreatography (ERCP) and stent placement are considerably safer than surgical biliary decompression
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Elective cholecystectomy should be performed after resolution of acute cholangitis in patients with an intact gallbladder
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Meticulous disinfection and ERCP techniques are required to avoid the development of acute cholangitis in patients with biliary obstruction who undergo ERCP
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References
Leung, J. W. et al. Antibiotics, biliary sepsis, and bile duct stones. Gastrointest. Endosc. 40, 716–721 (1994).
Leung, J. W. et al. Bacteriologic analyses of bile and brown pigment stones in patients with acute cholangitis. Gastrointest. Endosc. 54, 340–345 (2001).
Newman, H. F. & Northup, J. D. The autopsy incidence of gallstones. Surg. Gynecol. Obstet. 109, 1–13 (1959).
Jorgensen, T., Kay, L. & Schultz-Larsen, K. The epidemiology of gallstones in a 70-year-old Danish population. Scand. J. Gastroenterol. 25, 335–340 (1990).
The MICOL Group. In Recent Advances in the Epidemiology and Prevention of Gallstone Disease (eds Capocaccia, L. et al.) 37–44 (Kluwer, Boston, 1991).
Everhart, J. E., Khare, M., Hill, M. & Maurer, K. R. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 117, 632–639 (1999).
Neuhaus, H. et al. Prospective evaluation of the use of endoscopic retrograde cholangiography before laparoscopic cholecystectomy. Endoscopy 24, 745–749 (1992).
Saltzstein, E. C., Peacock, J. B. & Thomas, M. D. Preoperative bilirubin, alkaline phosphatase and amylase levels as predictors of common duct stones. Surg. Gynecol. Obstet. 154, 381–384 (1982).
Lacaine, F., Corlette, M. B. & Bismuth, H. Preoperative evaluation of the risk of common bile duct stones. Arch. Surg. 115, 1114–1116 (1980).
Houdart, R., Perniceni, T., Darne, B., Salmeron, M. & Simon, J. F. Predicting common bile duct lithiasis: determination and prospective validation of a model predicting low risk. Am. J. Surg. 170, 38–43 (1995).
Welbourn, C. R., Mehta, D., Armstrong, C. P., Gear, M. W. & Eyre-Brook, I. A. Selective preoperative endoscopic retrograde cholangiography with sphincterotomy avoids bile duct exploration during laparoscopic cholecystectomy. Gut 37, 576–579 (1995).
McSherry, C. K., Ferstenberg, H., Calhoun, W. F., Lahman, E. & Virshup, M. The natural history of diagnosed gallstone disease in symptomatic and asymptomatic patients. Ann. Surg. 202, 59–63 (1985).
Friedman, G. D. Natural history of asymptomatic and symptomatic gallstones. Am. J. Surg. 165, 399–404 (1993).
Charcot, J. M. Lecons sur les maladies du fore des voices biliares et des veins faites à la Faculté de Médicine de Paris [French]. (Recueillies et publliées par Bournesville et Sevestre, Paris, 1877) English translation (New York, 1878).
Lai, E. C. et al. Endoscopic biliary drainage for severe acute cholangitis. N. Engl. J. Med. 326, 1582–1586 (1992).
Leung, J. W., Chung, S. C., Sung, J. J., Banez, V. P. & Li, A. K. Urgent endoscopic drainage for acute suppurative cholangitis. Lancet 1, 1307–1309 (1989).
Wada, K. et al. Diagnostic criteria and severity assessment of acute cholangitis: Tokyo guidelines. J. Hepatobiliary Pancreat. Surg. 14, 52–58 (2007).
Huang, T., Bass, J. A. & Williams, R. D. The significance of biliary pressure in cholangitis. Arch. Surg. 98, 629–632 (1969).
Clements, W. D. et al. Role of the gut in the pathophysiology of extrahepatic biliary obstruction. Gut 39, 587–593 (1996).
Raper, S. E., Barker, M. E., Jones, A. L. & Way, L. A. Anatomic correlates of bacterial cholangiovenous reflux. Surgery 105, 352–359 (1989).
Sung, J. Y. et al. Bacterial invasion of the biliary system by way of the portal venous system. Hepatology 14, 313–317 (1991).
Sung, J. Y. et al. Ascending infection of the biliary tract after surgical sphincterotomy and biliary stenting. J. Gastroenterol. Hepatol. 7, 240–245 (1992).
Sung, J. Y., Costerton, J. W. & Shaffer, E. A. Defense system in the biliary tract against bacterial infection. Dig. Dis. Sci. 37, 689–696 (1992).
Subhani, J. M., Kibbler, C. & Dooley, J. S. Review article: antibiotic prophylaxis for endoscopic retrograde cholangiopancreatography (ERCP). Aliment. Pharmacol. Ther. 13, 103–116 (1999).
Parks, R. W. et al. Intestinal barrier dysfunction in clinical and experimental obstructive jaundice and its reversal by internal biliary drainage. Br. J. Surg. 83, 1345–1349 (1996).
Parks, R. W. et al. Change in gastrointestinal morphology associated with obstructive jaundice. J. Pathol. 192, 526–532 (2000).
Sileri, P. et al. Bacterial translocation and intestinal morphological findings in jaundiced rats. Dig. Dis. Sci. 4, 929–934 (2002).
Csendes, A. et al. Common bile duct pressure in patients with common bile duct stones with or without acute suppurative cholangitis. Arch. Surg. 123, 697–699 (1988).
Kuzu, M. A. et al. Obstructive jaundice promotes bacterial translocation in human. Hepatogastroenterology 46, 2159–2164 (1999).
White, J. S., Hoper, M., Parks, R. W., Clements, W. D. & Diamond, T. Patterns of bacterial translocation in experimental biliary obstruction. J. Surg. Res. 132, 80–84 (2006).
Flemma, R. J., Flint, L. M., Osterhaout, S. & Shingleton, W. W. Bacteriologic studies of biliary infection. Ann. Surg. 166, 563–572 (1967).
Yamamoto, S. et al. The effect of biliary decompression on antibiotic biliary excretion. Hepatogastroenterology 49, 330–334 (2002).
Rerknimitr, R. et al. Microbiology of bile in patients with cholangitis or cholestasis with and without plastic biliary endoprosthesis. Gastrointest. Endosc. 56, 885–889 (2002).
Landau, O., Kott, I., Deutsch, A. A., Stelman, E. & Reiss, R. Multifactorial analysis of septic bile and septic complications in biliary surgery. World J. Surg. 16, 962–965 (1992).
Csendes, A., Diaz, J. C., Burdiles, P., Maluenda, F. & Morales, E. Risk factors and classification of acute suppurative cholangitis. Br. J. Surg. 79, 655–658 (1992).
Reynolds, B. M. & Dargan, E. L. Acute obstructive cholangitis. A distinct clinical syndrome. Ann. Surg. 150, 200–304 (1959).
Takahashi, Y., Takahashi, T., Takahashi, W. & Sato, T. Morphometrical evaluation of extrahepatic bile ducts in reference to their structural changes with aging. Tohoku J. Exp. Med. 147, 301–309 (1985).
Feng, B. & Song, Q. Does the common bile duct dilate after cholecystectomy? Sonographic evaluation in 234 patients. AJR Am. J. Roentgenol. 165, 859–861 (1995).
Wachsberg, R. H., Kim, K. H. & Sundaram, K. Sonographic versus endoscopic retrograde cholangiographic measurements of the bile duct revisited: importance of the transverse diameter. AJR Am. J. Roentgenol. 170, 669–674 (1998).
Bachar, G. N., Cohen, M., Belenky, A., Atar, E. & Gideon, S. Effect of aging on the adult extrahepatic bile duct: a sonographic study. J. Ultrasound Med. 22, 879–882 (2003).
Behar, J. et al. Functional gallbladder and sphincter of Oddi disorders. Gastroenterology 130, 1498–1509 (2006).
Holzknecht, N. et al. Breath-hold MR cholangiography with snapshot techniques: prospective comparison with endoscopic retrograde cholangiography. Radiology 206, 657–664 (1998).
Lomas, D. J., Bearcroft, P. W. & Gimson, A. E. MR cholangiopancreatography: prospective comparison of a breath-hold 2D projection technique with diagnostic ERCP. Eur. Radiol. 9, 1411–1417 (1999).
Varghese, J. C. et al. A prospective comparison of magnetic resonance cholangiopancreatography with endoscopic retrograde cholangiopancreatography in the evaluation of patients with suspected biliary tract disease. Clin. Radiol. 54, 513–520 (1999).
Varghese, J. C. et al. Diagnostic accuracy of magnetic resonance cholangiopancreatography and ultrasound compared with direct cholangiography in the detection of choledocholithiasis. Clin. Radiol. 55, 25–35 (2000).
Soto, J. A., Barish, M. A., Alvarez, O. & Medina, S. Detection of choledocholithiasis with MR cholangiography: comparison of three-dimensional fast spin-echo and single- and multisection half-Fourier rapid acquisition with relaxation enhancement sequences. Radiology 215, 737–745 (2000).
Demartines, N. et al. Evaluation of magnetic resonance cholangiography in the management of bile duct stones. Arch. Surg. 135, 148–152 (2000).
Guarise, A., Baltieri, S., Mainardi, P. & Faccioli, N. Diagnostic accuracy of MRCP in choledocholithiasis [Italian]. Radiol. Med. 109, 239–251 (2005).
Amouyal, P. et al. Diagnosis of choledocholithiasis by endoscopic ultrasonography. Gastroenterology 106, 1062–1067 (1994).
Sugiyama, M. & Atomi, Y. Endoscopic ultrasonography for diagnosing choledocholithiasis: a prospective comparative study with ultrasonography and computed tomography. Gastrointest. Endosc. 45, 143–146 (1997).
Verma, D., Kapadia, A., Eisen, G. M. & Adler, D. G. EUS vs MRCP for detection of choledocholithiasis. Gastrointest. Endosc. 64, 248–254 (2006).
Sgouros, S. N. & Bergele, C. Endoscopic ultrasonography versus other diagnostic modalities in the diagnosis of choledocholithiasis. Dig. Dis. Sci. 51, 2280–2286 (2006).
Ozden, I. et al. Endoscopic and radiologic interventions as the leading causes of severe cholangitis in a tertiary referral center. Am. J. Surg. 189, 702–706 (2005).
Einstein, D. M., Lapin, S. A., Ralls, P. W. & Halls, J. M. The insensitivity of sonography in the detection of choledocholithiasis. AJR Am. J. Roentgenol. 142, 725–728 (1984).
Mitchell, S. E. & Clark, R. A. A comparison of computed tomography and sonography in choledocholithiasis. AJR Am. J. Roentgenol. 142, 729–733 (1984).
Polkowski, M., Palucki, J., Regula, J., Tilszer, A. & Butruk, E. Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: a prospective blinded study in non-jaundiced patients. Gut 45, 744–749 (1999).
Kondo, S. et al. Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography. Eur. J. Radiol. 54, 271–275 (2005).
Reiss, R., Eliashiv, A. & Deutsch, A. A. Septic complications and bile cultures in 800 consecutive cholecystectomies. World J. Surg. 6, 195–199 (1982).
Siegman-Igra, Y., Isakov, A., Inbar, G. & Cahaner, J. Pseudomonas aeruginosa septicaemia following endoscopic retrograde cholangiopancreatography with a contaminated endoscope. Scand. J. Infect. Dis. 19, 527–530 (1987).
Sinanan, M. Acute cholangitis. Infect. Dis. Clin. North Am. 6, 571–599 (1992).
Hanau, L. & Steigbigel, N. Cholangitis: pathogenesis, diagnosis, and treatment. Curr. Clin. Top. Infect. Dis. 15, 153–178 (1995).
Westphal, J. & Brogard, J. Biliary tract infections: a guide to drug treatment. Drugs 57, 81–91 (1999).
Hanau, L. & Steigbigel, N. Acute (ascending) cholangitis. Infect. Dis. Clin. North Am. 14, 521–546 (2000).
Swidsinski, A. & Lee, S. P. The role of bacteria in gallstone pathogenesis. Front. Biosci. 6, E93–E103 (2001).
Kumar, R., Sharma, B. C., Singh, J. & Sarin, S. K. Endoscopic biliary drainage for severe acute cholangitis in biliary obstruction as a result of malignant and benign diseases. J. Gastroenterol. Hepatol. 19, 994–997 (2004).
Tanaka, A. et al. Antimicrobial therapy for acute cholangitis: Tokyo guidelines. J. Hepatobiliary Pancreat. Surg. 14, 59–67 (2007).
van Lent, A. U. et al. Duration of antibiotic therapy for cholangitis after successful endoscopic drainage of the biliary tract. Gastrointest. Endosc. 55, 518–522 (2002).
Carpenter, C. F. & Swami, A. Cholangitis. Johns Hopkins POC-IT ABX Guide (Ed. Barlett, J. G.) [online], (2008).
Leung, J. W., Chan, R. C., Cheung, S. W., Sung, J. Y. & Chung, S. C. S. The effect of obstruction on the biliary excretion of cefoperazone and ceftriaxone. J. Antimicrob. Chemother. 25, 399–406 (1990).
Williams, E. J. et al. Guidelines on the management of common bile duct stones (CBDS). Gut 57, 104–121 (2008).
Attasaranya, S., Fogel, E. L. & Lehman, G. A. Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis. Med. Clin. North Am. 92, 925–960 (2008).
Hui, C. K. et al. Acute cholangitis—predictive factors for emergency ERCP. Aliment. Pharmacol. Ther. 15, 1633–1637 (2001).
National Institutes of Health State-of-the-Science Conference Statement on Endoscopic Retrograde Cholangiopancreatography (ERCP) for Diagnosis and Therapy [online], (2002).
Adler, D. G. et al. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas. Gastrointest. Endosc. 62, 1–8 (2005).
Speer, A. G. et al. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 2, 57–62 (1987).
Sugiyama, M. & Atomi, Y. Treatment of acute cholangitis due to choledocholithiasis in elderly and younger patients. Arch. Surg. 132, 1129–1133 (1997).
Sugiyama, M. & Atomi, Y. The benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis. Am. J. Gastroenterol. 93, 2065–2068 (1998).
Deviere, J. et al. Septicaemia after endoscopic retrograde cholangiopancreatography. Endoscopy 22, 72–75 (1990).
Gigot, J. F. et al. Acute cholangitis: multivariate analysis of risk factors. Ann. Surg. 209, 435–438 (1988).
Hintze, R. E. et al. Magnetic resonance cholangiopancreatography-guided unilateral endoscopic stent placement for Klatskin tumours. Gastrointest. Endosc. 53, 40–46 (2001).
Harewood, G. C. & Baron, T. H. Cost analysis of magnetic resonance cholangiography in the management of inoperable hilar biliary obstruction. Am. J. Gastroenterol. 97, 1152–1158 (2003).
Lee, D. W. et al. Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: a prospective randomized trial. Gastrointest. Endosc. 56, 361–365 (2002).
De Palma, G. D., Galloro, G., Siciliano, S., Iovino, P. & Catanzano, C. Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study. Gastrointest. Endosc. 53, 547–553 (2001).
Chopra, K. B. et al. Randomised study of endoscopic biliary endoprosthesis versus duct clearance for bile duct stones in high risk patients. Lancet 348, 791–793 (1996).
Feitoza, A. B. & Baron, T. H. Endoscopy and ERCP in the setting of previous upper GI tract surgery. Part I: reconstruction without alteration of pancreaticobiliary anatomy. Gastrointest. Endosc. 54, 743–749 (2001).
Feitoza, A. B. & Baron, T. H. Endoscopy and ERCP in the setting of previous upper GI tract surgery. Part II: postsurgical anatomy with alteration of the pancreaticobiliary tree. Gastrointest. Endosc. 55, 75–79 (2002).
Koornstra, J. J., Fry, L. & Monkemuller, K. ERCP with the balloon-assisted enteroscopy technique: a systematic review. Dig. Dis. 26, 324–329 (2008).
Gupta, N., Rajwanshi, A., Srinivasan, R. & Nijhawan, R. Pathology of supraclavicular lymphadenopathy in Chandigarh, north India: an audit of 200 cases diagnosed by needle aspiration. Cytopathology 17, 94–96 (2006).
Taylor, K. J. W., Rosenfield, A. T. & Spiro, H. M. Diagnostic accuracy of grey scale ultrasonography for the jaundiced patient. A report of 275 cases. Arch. Intern. Med. 139, 60–63 (1979).
Hakansson, K., Ekberg, O., Hakansson, H. O. & Leander, P. MR and ultrasound in screening of patients with suspected biliary tract disease. Acta Radiol. 43, 80–86 (2002).
Romagnuolo, J. et al. Magnetic resonance cholangiopancreatography: a meta analysis of test performance in suspected biliary disease. Ann. Intern. Med. 139, 547–557 (2003).
Hammarstrom, L. E., Holmin, T., Stridbeck, H. & Ihse, I. Long term follow up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ. Br. J. Surg. 82, 1516–1521 (1995).
Targarona, E. M. et al. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high risk patients. Lancet 347, 926–929 (1996).
Boerma, D. et al. Wait and see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile duct stones. A randomised trial. Lancet 360, 761–765 (2002).
Lau, J. Y. et al. Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients. Gastroenterology 130, 96–103 (2006).
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Lee, J. Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol 6, 533–541 (2009). https://doi.org/10.1038/nrgastro.2009.126
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DOI: https://doi.org/10.1038/nrgastro.2009.126
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