PATHOPHYSIOLOGY AND

MANAGEMENT OF ACUTE
CHOLANGITIS
Henny Stephani
A. M. Luthfi Parewangi

Division Of Gastroenterohepatology
Internal Medicine Department
Faculty of Medicine, Hasanuddin University
2022
 VISI
Menjadi pusat pendidikan yang unggul, mandiri
dan bermartabat untuk menghasilkan Dokter
Spesialis Ilmu Penyakit Dalam yang berkualitas
dan mampu bersaing secara regional, nasional
maupun global pada tahun 2025, dengan
didukung oleh sumber daya manusia yang
profesional dan bertanggung jawab.
 VISI
• Menyelenggarakan Pendidikan di bidang Ilmu
Penyakit Dalam dan riset
• Memberikan pelayanan Kesehatan di bidang Ilmu Penyakit
Dalam dengan pendekatan kultural dan budaya secara
paripurna dan bermutu
• Meningkatkan kuantitas dan kualitas penelitian dasar dan
aplikatif Ilmu Penyakit Dalam yang bertaraf Internasional
• Menciptakan sistem manajemen program Studi Ilmu Penyakit
Dalam yang transparan, akuntabel, responsible, independent,
terintegrasi dan berkeadilan
 INTRODUCTION
The word cholangitis is a pathologic term that
means “inflammation of bile ducts.” It is a broad
term and does not imply any specific diagnosis.

In clinical practice, cholangitis is defined on the

basis of symptoms and signs of systemic sepsis
originating in the biliary tract

Zaheer Nabi, Andrew Korman, Nageshwar Reddy, et al. Infections of the Biliary Tract. Third Edit. Clinical Gastrointestinal Endoscopy. Elsevier Inc ;
2021. P 636-651.e3
 INTRODUCTION
• In 1877, charcot first described the The charcot’s triad >>
Charcot’s triad >> a clinical pattern severily limited & the
with intermittent fever accompanied clinical presentation of
by chills and rigor, right upper the disease has wide
abdominal pain and jaundice. spectrum range

• In 1959, Reynolds and Dragan

described a syndrome consisting of
fever, jaundice, abdominal pain, updated Tokyo
altered mental status (confusion or Guideline (TG18
lethargy), and shock
Kimura Y, Takada T, Kawarada Y, et al Defi nitions , pathophysiology , and epidemiology of acute cholangitis and cholecystitis : Tokyo Guidelines. Journal of HBP surgery. 2007. 14:15–26
Christeven R, Freandy, Andersen, et al. Acute Cholangitis : An Update in Management Based on Severity Assessment. The Indonesian Journal of Gastroenterology, Hepatology and Digestive
Endoscopy. 2018. 170–7.
Lan D, Wah C, Christophi C, et all. Acute cholangitis : current concepts. ANZJsurg. 2017
ANATOMY
 EPIDEMIOLOGY
The incidence of acute cholangitis ranges from 0.3to 1.6% with a
proportion of severe cholangitis thatreaches 12.3%

Less than 200.000 casesof cholangitis occur per year in the United
States.

Males and females are equally affected.The average age of patients

presenting with acutecholangitis is 50 to 60 years

The most common characteristics that predispose patients to the

development of cholangitis are bile duct stones and previous
manipulation of
the biliary tree, including stenting and biliary surgeryresulting in
stricture.
Christeven R, Freandy, Andersen, et al. Acute Cholangitis : An Update in Management Based on Severity Assessment. The Indonesian Journal of
Gastroenterology, Hepatology and Digestive Endoscopy. 2018. 170–7.
 ETIOLOGY

Wang Z, Ahmed S, and Shelat VG. Acute Cholangitis. Springer International Publishing AG. 2018;65–81.
 Patophisiology

Tringali A. Endoscopic management of acute cholangitis. Gastroenterol Hepatol Open Access. 2016;5(2):38–43.
 Diagnosis
spectrum of clinical presentations of cholangitis, ranging from mild
forms to severe forms, including overwhelming fulminant sepsis
Symptoms : Physical exam :
● Fever ● fever
● Chills ● jaundice
● Malaise ● right upper quadrant
● Rigors tenderness
● generalized abdominal pain ● abdominal distension
● jaundice ● altered mental status, or
● pruritus hemodynamic instability.
● pale stools.

Virgile J and marathu R Cholangitis - 2021, StatPearls Publishing LLC

Tringali A. Endoscopic management of acute cholangitis. Gastroenterol Hepatol Open Access. 2016;5(2):38–43.
Wang Z, Ahmed S, and Shelat VG. Acute Cholangitis. Springer International Publishing AG. 2018;65–81.
Alizadeh AHM. Cholangitis: Diagnosis, treatment and prognosis. J Clin Transl Hepatol. 2017;5(4):404–13.
 Charcot triad >> fever,
right upper abdominal Diagnosis
pain, &jaundice.
The Reynolds pentad +
altered mental status
&sepsis to the triad. sensitivity is
low (26.4%)

 specificity (95.9%)
Virgile J and marathu R Cholangitis - 2021, StatPearls Publishing LLC
Tringali A. Endoscopic management of acute cholangitis. Gastroenterol Hepatol Open Access. 2016;5(2):38–43.
Wang Z, Ahmed S, and Shelat VG. Acute Cholangitis. Springer International Publishing AG. 2018;65–81.
Alizadeh AHM. Cholangitis: Diagnosis, treatment and prognosis. J Clin Transl Hepatol. 2017;5(4):404–13.
 TG18/TG13 diagnostic criteria for acute cholangitis
Suspected diagnosis
A. Systemic inflammation One item in A 1 one item
in B or C
• A-1. Fever and/or shaking chills Certain diagnosis
• A-2. Laboratory data: evidence of inflammatory response One item in A, B, and C

B. Cholestasis
• B-1. Jaundice
• B-2. Laboratory data: abnormal liver function tests
C. Imaging
• C-1. Biliary dilatation
• C-2. Evidence of the etiology on imaging (stricture, stone,
stent etc.)
Kiriyama S, Kozaka K, Takada T , et al. Tokyo Guidelines 2018 : diagnostic criteria and severity grading of acute cholangitis ( with videos ). Springer International Publishing AG.
2018;17–30.
 TG18/TG13 severity assessment criteria for AC
Grade III (severe) AC the onset of dysfunction at least in any one of :
CV dysfunction: hypotension requiring dopamine ≥5 lg/kg per min, or
any dose of norepinephrine

2. Neurological dysfunction: disturbance of consciousness

3. Respiratory dysfunction: PaO2/FiO2 ratio <300

4. Renal dysfunction : oliguria, serum creatinine >2.0 mg/dl

5. Hepatic dysfunction: PT-INR >1.5

6. Hematological dysfunction : platelet count <100,000/mm3

Kiriyama S, Kozaka K, Takada T , et al. Tokyo Guidelines 2018 : diagnostic criteria and severity grading of acute cholangitis ( with videos ). Springer International Publishing AG.
 TG18/TG13 severity assessment criteria for AC
Grade II (moderate)  associated with any two of the following conditions:

1. Abnormal WBC count (>12,000/mm3, <4,000/mm3)

2. High fever (≥39°C)

3. Age (≥75 years old)

4. Hyperbilirubinemia (total bilirubin ≥5 mg/dl)

5. Hypoalbuminemia (<STDa90.7)
 “Grade I” mild AC does not meet the criteria of “Grade III
(severe)” or “Grade II (moderate)” acute cholangitis at initial
diagnosis.

Kiriyama S, Kozaka K, Takada T , et al. Tokyo Guidelines 2018 : diagnostic criteria and severity grading of acute cholangitis ( with videos ). Springer International Publishing AG.
2018;17–30.
 Imaging

USG abdomen

Ely R, Mha DO, Long B, Koyfman A. The emergency medicine- fokused review of cholangitis. J Emerg Med . 2017;1–9.
 Ct scan abdomen

Ely R, Mha DO, Long B, Koyfman A. The emergency medicine- fokused review of cholangitis. J Emerg Med . 2017;1–9.
 MRCP

Kiriyama S, Kozaka K, Takada T , et al. Tokyo Guidelines 2018 : diagnostic criteria and severity grading of acute cholangitis ( with videos ). Springer International
Publishing AG. 2018;17–30.
 MANAGEMENT

Miura F, Okamoto K, Takada T, et all. Tokyo Guidelines 2018 : initial management of acute biliary infection and fl owchart for acute cholangitis. J Hepatobiliary
Pancreat Sci 2018;31–40.
 Antimicrobial recommendations for grade I AC(mild)

Christeven R, Freandy, Andersen, et al. Acute Cholangitis : An Update in Management Based on Severity Assessment. The Indonesian Journal of
Gastroenterology, Hepatology and Digestive Endoscopy. 2018. 170–7.
 Antimicrobial recommendations for grade II AC

Christeven R, Freandy, Andersen, et al. Acute Cholangitis : An Update in Management Based on Severity Assessment. The Indonesian Journal of
Gastroenterology, Hepatology and Digestive Endoscopy. 2018. 170–7.
 Antimicrobial recommendations for grade III AC

Christeven R, Freandy, Andersen, et al. Acute Cholangitis : An Update in Management Based on Severity Assessment. The Indonesian Journal of
Gastroenterology, Hepatology and Digestive Endoscopy. 2018. 170–7.
 Endoscopic Procedures
• Endoscopic retrograde cholangiopancreatography
• Endoscopic nasobiliary drainage
• Percutaneous Transhepatic Cholangiography
• EUS-guided drainage transpapillary dan transmural

An Z, Braseth AL, and Sahar N. Acute Cholangitis. Gastroenterol Clin NA. 2021;50(2):403–14.
Buxbaum JL, Buitrago C. Lee A. ASGE guideline on the management of cholangitis. Gastrointest Endosc.. 2021;94(2):207-221.e14.
 ERCP

Adger DG. Current Management of Ascending Cholangitis. Practical Gastroenterology. 2018.

 Surgery
Surgery is now a last option because it is associated with high
morbidity and mortality for patients with severe acute cholangitis.
Surgical management, however, must still be considered if the
patient’s condition is deteriorating without a nonoperative means
of biliary decompression.

Adger DG. Current Management of Ascending Cholangitis. Practical Gastroenterology. 2018. P 28-45.
Dageforde LA, Lillemoe KD. Management of Acute Cholangitis [Internet]. Thirteenth. Current Surgical Therapy. Elsevier; 2021. 457–462 p. 457-61.
 Complications

Hepatic abscess
Acute cholecystitis
Portal vein thrombosis
Acute biliary pancreatitis
Liver failure
Acute renal failure
Bacteremia/septicemia
Multiple organ failure
Virgile J and marathu R Cholangitis - 2021, StatPearls Publishing LLC
 Prognosis
Most cases of acute cholangitis resolve with antibiotics and
nonsurgical biliary drainage (∼85%); however, morbidity and
mortality can be high when patients are immunocompromised or
elderly.

Overall, with better nonsurgical drainage techniques and fewer

cases requiring operative intervention, the mortality rate has
decreased significantly in the past 30 years.

Dageforde LA, Lillemoe KD. Management of Acute Cholangitis. Thirteenth. Current Surgical Therapy.
Elsevier; 2021. 457–462 p. 457-61
 Summary

• Cholangitis is a life-threatening condition that occurs due to biliary

obstruction & bacterial infiltration of the biliary tract.
• Two main pathomechanisms of acute cholangitis are obstruction of
the biliary tract by an obstacle & bacterial proliferation in bile.
• Charcot’s triad is well known for classic symptom in cholangitis, but
because sometimes several patient come with no classic symptom,
tokyo guideline is used for making the diagnose
• The main of management of acute cholangitis is fluid resuscitation,
appropriate broad-spectrum antibiotics, and biliary decompression.
Thank You