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Bacterial Cholangitis
AUTHORS & AFFILIATIONS
Turdaliev Samatbek [ https://orcid.org/0000-0002-0836-0671 ]
Aditya Borbale
Om Ratnaparkhi
(1, Teacher, International Medical Faculty, Osh State University; Republic of Kyrgyzstan
2, Student, International Medical Faculty, Osh State University; Republic of Kyrgyzstan
3, Student, International Medical Faculty, Osh State University; Republic of Kyrgyzstan)
Abstract
Bacterial cholangitis, also known as acute cholangitis, is a potentially life-threatening infection of the biliary tract caused by bacterial invasion secondary to biliary obstruction. It commonly arises due to gallstones, biliary strictures, or malignancy obstructing bile flow, allowing ascending infection from the duodenum.
The condition is characterized clinically by Charcot’s triad (fever, jaundice, and right upper quadrant pain), and in severe cases, Reynolds’ pentad (Charcot’s triad plus hypotension and altered mental status).
This study provides a comprehensive review of the etiology, pathogenesis, clinical presentation, diagnostic criteria, management strategies, and prognostic outcomes associated with bacterial cholangitis, highlighting advances in endoscopic and antibiotic therapy.
Introduction
Bacterial cholangitis is an acute infection of the biliary system that occurs when there is obstruction to bile flow, allowing bacterial proliferation within the biliary tree. The most common cause is choledocholithiasis (common bile duct stones), but it can also result from biliary strictures, tumors, or iatrogenic causes such as endoscopic retrograde cholangiopancreatography (ERCP).
Common Causative Organisms:
· Escherichia coli (most common)
· Klebsiella species
· Enterococcus species
· Pseudomonas aeruginosa
· Enterobacter species
Risk Factors:
· Gallstones and bile duct stones
· Biliary malignancy
· Biliary stents or prior biliary surgery
· Pancreatic carcinoma
· Immunosuppression
· Advanced age and diabetes mellitus
Prompt diagnosis and treatment are essential to prevent sepsis and multiorgan failure.
Methods
A structured literature review was performed using PubMed, Scopus, Google Scholar, and Cochrane Library databases (2013–2023). The focus was on recent clinical guidelines, case series, and treatment trials involving human subjects.
Search Terms Used:
“Bacterial cholangitis,” “acute cholangitis,” “Charcot’s triad,” “biliary obstruction,” “ERCP,” “bile duct infection,” “antibiotic therapy,” “biliary drainage,” “Tokyo Guidelines.”
Inclusion Criteria:
· Peer-reviewed clinical studies in English
· Human-based research (2013–2023)
· Articles on diagnosis, management, and outcomes
Exclusion Criteria:
· Animal studies or non-English papers
· Isolated case reports without clinical relevance
· Studies prior to 2013 unless foundational
Diagnostic Criteria and Techniques
The Tokyo Guidelines (TG18) provide the most widely accepted diagnostic criteria for bacterial cholangitis, based on clinical, laboratory, and imaging findings:
1. Clinical Features:
· Fever and/or chills
· Jaundice
· Right upper quadrant pain
2. Laboratory Findings:
· Elevated leukocyte count
· Elevated serum bilirubin
· Increased liver enzymes (ALP, GGT, AST, ALT)
3. Imaging Findings:
· Biliary dilatation on ultrasound, CT, or MRI
· Evidence of biliary obstruction (e.g., stones, strictures)
Diagnosis:
Definite acute cholangitis is made when all three criteria (clinical, laboratory, imaging) are fulfilled.
Imaging Modalities:
Ultrasound: Initial investigation; detects biliary dilation and stones.
CT Scan: Identifies cause and extent of obstruction.
Magnetic Resonance Cholangiopancreatography (MRCP): Non-invasive evaluation of biliary anatomy.
Endoscopic Retrograde Cholangiopancreatography (ERCP): Both diagnostic and therapeutic for biliary drainage.
Results
1. Epidemiology:
· Most prevalent in adults >50 years.
· Gallstones are the leading cause (~60–70%).
· Male-to-female ratio approximately 1.2:1.
2. Clinical Presentation:
· Charcot’s triad: Fever, jaundice, right upper quadrant pain (seen in ~50–70% cases).
· Reynolds’ pentad: Triad + hypotension + altered sensorium (severe sepsis).
· Symptoms may progress rapidly to septic shock if untreated.
3. Microbiology:
· E. coli (~45–60%), Klebsiella, Enterococcus, and Pseudomonas are predominant isolates.
· Polymicrobial infection is common.
4. Management:
Initial Management:
Hemodynamic stabilization (IV fluids, oxygen, vasopressors if needed)
Broad-spectrum IV antibiotics covering Gram-negative and anaerobic organisms:
Piperacillin–tazobactam
Ceftriaxone + Metronidazole
Carbapenems in resistant cases
Definitive Management (Source Control):
Endoscopic Biliary Drainage (ERCP): Gold standard for relieving obstruction.
Percutaneous Transhepatic Biliary Drainage (PTBD): Alternative when ERCP fails.
Surgical drainage (choledochotomy or cholecystectomy) in selected cases.
5. Prognosis:
· Mortality rate: 5–10% (decreases with timely intervention).
· Prognosis worsens with delayed drainage, advanced age, or comorbidities.
Discussion
Bacterial cholangitis represents a medical emergency where biliary obstruction and infection coexist. The condition evolves rapidly and can lead to septicemia and multiorgan failure if drainage is delayed.
Early recognition through Tokyo Guidelines criteria and prompt initiation of antibiotics can dramatically improve outcomes. Among treatment modalities, ERCP has revolutionized management, offering both diagnosis and therapy in a single session.
However, challenges remain, particularly in low-resource settings where access to endoscopy is limited. Delayed drainage and inappropriate antibiotic use contribute to higher morbidity and mortality. Moreover, increasing antibiotic resistance among Enterobacteriaceae species poses an emerging threat.
To mitigate these challenges, the following measures are recommended:
· Strengthening early recognition protocols and training healthcare professionals.
· Ensuring availability of emergency ERCP or PTBD in tertiary centers.
· Regular antibiotic stewardship programs to reduce resistance.
· Development of rapid diagnostic tools for early pathogen identification.
A multidisciplinary approach involving gastroenterologists, surgeons, infectious disease specialists, and intensivists is crucial for optimizing outcomes.
Conclusion
Bacterial cholangitis remains a critical biliary infection with significant morbidity and mortality if untreated. Timely diagnosis, antibiotic therapy, and biliary decompression form the cornerstone of management.
Advances in endoscopic and imaging technologies have significantly improved survival rates and reduced invasive surgical requirements. Nevertheless, delayed presentation, limited access to specialized care, and antibiotic resistance remain ongoing challenges.
Preventive measures such as early detection and management of biliary stones, post-ERCP care, and public awareness are vital in reducing disease incidence.
Ultimately, successful management of bacterial cholangitis requires a rapid, coordinated response combining clinical acumen, modern technology, and evidence-based antibiotic use.
References
Kiriyama S, Kozaka K, Takada T, et al. (2018). Tokyo Guidelines 2018: Diagnostic criteria and severity grading of acute cholangitis. Journal of Hepato-Biliary-Pancreatic Sciences, 25(1), 17–30.
https://doi.org/10.1002/jhbp.512
Gomi H, Solomkin JS, Takada T, et al. (2018). TG18: Antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci, 25(1), 3–16.
https://doi.org/10.1002/jhbp.517
Boey JH, Way LW. (1980). Acute cholangitis. Annals of Surgery, 191(3), 264–270.
https://doi.org/10.1097/00000658-198003000-00005
Sung JY, Costerton JW, Shaffer EA. (1992). Bacterial biofilm formation within the biliary system: A possible mechanism of stent blockage. J Hepatol, 16(2), 219–224.
https://doi.org/10.1016/S0168-8278(05)80669-5
Kiriyama S, Takada T, Strasberg SM, et al. (2013). New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo Guidelines (TG13). J Hepatobiliary Pancreat Sci, 20(1), 24–34.
