Clinical ManifestationsPatients with acute cholangitis usually have a prior history of biliary tract disease, particularly cholelithiasis or choledochelithiasis. The onset of cholangitis is usually acute, with high fevers, rigors, and abdominal pain. The classic Charcot triad of fever, RUQ abdominal pain, and jaundice can be found in up to 70% of cases. Patients with acute obstructive suppurative cholangitis, in which there is pus in the biliary tree, may additionally present with altered mental status and hypotension (Reynold's pentad). These extra findings are typically due to the presence of gram-negative sepsis, particularly by Escherichia coli or Klebsiella pneumoniae. A pyogenic liver abscess is a rare complication on acute cholangitis.
DiagnosisMost patients with acute cholangitis have marked leukocytosis, hyperbilirubinemia, and elevated alkaline phosphatase levels, but serum transaminases are usually only modestly elevated. Up to one third of cases have hyperamylasemia caused by concomitant obstruction of the pancreatic duct.Ultrasonography is the preferred study to confirm the diagnosis because of its ability to identify dilated biliary ducts. Significant biliary ductal dilatation in a patient with the appropriate clinical picture confirms the diagnosis. Ultrasonographic examination can also evaluate the gallbladder size, the presence of stones, masses associated with the bile ducts, and liver parenchymal changes.Endoscopic retrograde cholangiopancreatography (ERCP) provides the most accurate means of determining the cause and location of obstruction. This is the procedure of choice if common bile duct stones are present, since stone extraction and biliary stent placement can be performed, decompressing the biliary system. MRCP may also allow visualization oil the biliary tree but does not permit removal of the obstruction.An abdominal CT scan can demonstrate the presence and, potentially, the cause of biliary obstruction. Plain radiography and HIDA scans are less useful in confirming the diagnosis.*107/348/5*
