Acute cholangitis

The patient with suspected acute cholangitis should undergo laboratory testing that typically demonstrates an increase in indices of inflammation (white blood cells, C-reactive protein) associated with elevation of indices of cholestasis (alkaline phosphatase, gamma-glutamyl transpeptidase) and bilirubin, particularly in its direct component. 

The first examination usually required in this circumstance is the ultrasound of the abdomen, non-invasive examination, which can be performed even at the patient's bedside, that allows to identify the dilatation of the intra- and/or extra-hepatic bile ducts and, in some cases, to identify the cause of cholangitis. 

Further investigation to define the cause of cholangitis is typically performed by Computed Axial Tomography (CT), which can visualize the site of the obstruction and the possible presence of lesions (inflammatory or tumor) supporting the obstruction. 

If, on the other hand, a more detailed study of the ductal system is required, MRI of the abdomen with cholangiographic sequences (MRCP) has greater diagnostic accuracy in identifying the site of biliary obstruction and/or the possible presence of choledocholithiasis. 

Echo-endoscopy (EUS), although a slightly more invasive endoscopic examination under sedation, but plays a key role in the diagnostic procedure of cholangitis as it represents the method with greater sensitivity for stones in the extra-hepatic biliary tract; moreover, in the presence of tumor lesions or narrowing it allows for sampling by needle aspiration for microscopic analysis. It also has the advantage of being able to be performed at the same time (in the same session, and with the same sedation) of the eventual therapeutic examination aimed at treating the cause of the obstruction.

Diagnosis of acute cholangitis involves hospitalization. Treatment of cholangitis is based on antibiotic therapy, supportive therapy (e.g., intravenous hydration, correction of any electrolyte imbalances), and resolution of obstruction by biliary drainage. 

Endoscopic Retrograde Cholangiopancreatography (ERCP) is an endoscopic method that allows for access to the bile duct and/or pancreatic duct through the intestine (duodenum) where these two ducts flow together. Access is endoscopic, but then radiology and contrast medium are used to study the ducts. Various accessories can be used to study the cause of the obstruction, to sample a possible stenosis for cytological examination, to extract stones of different sizes and, if necessary, to bypass the obstruction by placing plastic or metal biliary stents. It represents the first-line treatment to achieve biliary drainage during acute cholangitis. 

In some cases, specific anatomy or pathology may make retrograde access to the biliary route difficult or impossible. Operative echoendoscopy has developed over time multiple possibilities to help obtain biliary drainage when ERCP fails, either by lateral shunts (EUS-guided choledoco-duodenostomy; EUS-guided hepatico-gastrostomy) or by placement of guide wires that then allow normal ERCP to be performed. 

Percutaneous transhepatic biliary drainage performed by interventional radiologists is another option always available in case of failed endoscopic biliary drainage. In some very limited circumstances, biliary shunt surgery may be considered.