Cholangitis

Cholangitis — specifically acute bacterial cholangitis or ascending cholangitis — is an infection of the bile duct system, almost always occurring in the setting of biliary obstruction that allows intestinal bacteria to colonise and multiply within stagnant bile. The most common underlying causes are choledocholithiasis (common bile duct stones), biliary strictures (post-surgical or from cholangiocarcinoma), and pancreatic head malignancy. Organisms responsible include Escherichia coli, Klebsiella pneumoniae, Enterococcus faecalis, and anaerobes. Less common is primary sclerosing cholangitis (PSC), an autoimmune condition causing progressive fibro-inflammatory stricturing of intra- and extrahepatic bile ducts, and recurrent pyogenic cholangitis (hepatolithiasis), endemic in parts of Asia.

The clinical presentation of acute cholangitis ranges from mild to life-threatening. The classic Charcot's triad — fever with rigors, right upper quadrant pain, and jaundice — is present in only 50–70% of cases. The more severe Reynolds' pentad adds altered mental status and septic shock, indicating suppurative cholangitis requiring emergency decompression. Laboratory findings include leucocytosis, elevated bilirubin and alkaline phosphatase, and raised CRP. Blood cultures identify the causative organism in approximately 50% of cases. Ultrasound confirms biliary dilatation, and MRCP or CT clarifies the level and cause of obstruction.

Management requires prompt IV antibiotics (covering Gram-negative bacilli and anaerobes), fluid resuscitation, and — most critically — urgent biliary drainage. ERCP with sphincterotomy and stone removal is the first-line intervention for choledocholithiasis, achieving drainage in over 90% of cases. When ERCP fails or is unavailable, percutaneous transhepatic biliary drainage (PTBD) or surgical decompression via choledochotomy and T-tube placement are alternatives. Underlying causes such as biliary strictures or malignancy require definitive surgical management — biliary reconstruction (hepaticojejunostomy), stenting, or resection — after the patient has been stabilised. PSC is managed with regular endoscopic surveillance and transplantation in end-stage disease.