Acute Cholangitis

Acute cholangitis is a bacterial infection of the bile ducts that develops when bile flow is obstructed. The combination of biliary obstruction and bacterial colonisation allows infected bile under raised pressure to spill into the bloodstream, so the illness classically presents with fever, jaundice, and right-upper-quadrant pain and can progress to sepsis.

Definition

Acute cholangitis is an acute bacterial infection of the biliary tree, arising when an obstructed bile duct becomes colonised by bacteria and raised intraductal pressure allows infected bile to enter the systemic circulation.

Scope

The topic covers the two conditions required for cholangitis — biliary obstruction and bacterial contamination of bile — the ascending route of infection, the clinical syndrome, and the principle that infected obstructed bile must be drained. It is reference material describing the disease entity rather than individualised clinical management.

Core questions

• What two conditions must coincide for acute cholangitis to develop?
• How does infection ascend into and spread within the biliary tree?
• Why does obstructed, infected bile lead to systemic illness and sepsis?
• Why is relief of the biliary obstruction central to resolving the infection?

Key concepts

• Biliary obstruction plus bacterial contamination
• Ascending (retrograde) infection of the bile ducts
• Charcot triad (fever, jaundice, right-upper-quadrant pain)
• Reynolds pentad (Charcot triad plus hypotension and altered mental status)
• Cholangiovenous and cholangiolymphatic reflux
• Biliary drainage as definitive control

Mechanisms

Cholangitis requires two coincident conditions: obstruction of bile flow (most often by a common-duct stone, but also by strictures or tumours) and bacterial presence in the bile. Bacteria typically reach the ducts by ascending from the duodenum, though they may also arrive through portal blood. Behind an obstruction, intraductal pressure rises and disrupts the normal barrier between bile and the circulation, permitting cholangiovenous and cholangiolymphatic reflux of bacteria and endotoxin into the bloodstream. This produces the systemic features of infection that, in classic descriptions, manifest as fever, jaundice, and right-upper-quadrant pain (the Charcot triad) and, in severe disease with hypotension and confusion, the Reynolds pentad. Because the infection is sustained by the obstruction, decompression and drainage of the biliary tree are central to its resolution.

Clinical relevance

Acute cholangitis is a potentially life-threatening complication of biliary obstruction and a reference example of how mechanical obstruction and infection interact to cause sepsis. This entry describes the disease for educational purposes; it does not provide antibiotic selection, dosing, or procedural decisions, which are governed by clinical practice guidelines.

Epidemiology

Acute cholangitis most often complicates choledocholithiasis, so its occurrence parallels the burden of common-duct stones; benign and malignant strictures and instrumentation of the biliary tree are other recognised precipitants. Severity ranges from mild illness to severe disease with organ dysfunction.

History

The clinical syndrome was crystallised by Jean-Martin Charcot's nineteenth-century description of the triad of fever, jaundice, and right-upper-quadrant pain, later extended by Reynolds and Dargan to a pentad including shock and mental-status change in severe disease. Twentieth-century work clarified the dual requirement of obstruction and infection and the role of raised intraductal pressure, and modern consensus criteria such as the Tokyo Guidelines standardised diagnosis and severity grading.

Seminal works

• kiriyama-2018
• miura-2018
• williams-2017

Frequently asked questions

What two things have to happen for acute cholangitis to occur?

There must be both obstruction of bile flow and bacterial contamination of the bile; obstruction alone or bacteria alone is generally not enough, but together they allow infected bile under pressure to seed the bloodstream.

What is the Charcot triad?

It is the classic combination of fever, jaundice, and right-upper-quadrant pain that describes the typical presentation of acute cholangitis; when hypotension and altered mental status are added, it is called the Reynolds pentad and indicates severe disease.