Diagnostics

Acute cholangitis is diagnosed based on systemic signs of inflammation (fever, leukocytosis, ↑ CRP) in combination with signs of cholestasis (jaundice, ↑ GGT, ↑ ALP) and/or characteristic imaging findings (e.g., dilated CBD, periductal inflammation). Once the diagnosis is confirmed, disease severity should be assessed to determine the best approach to management

Charcot triad is not included in the diagnostic criteria because, although specific, it is not a sensitive criterion and may even be absent in patients with acute cholangitis.

• CBC: leukocytosis with left shift

• CRP: elevated

• LFTs: signs of cholestasis (↑ bilirubin, ↑ GGT, ↑ ALP, ↑ALT)

• Blood cultures (2 sets): obtain before administering antibiotics (especially in febrile patients). [1]

• Bile cultures: obtain during biliary drainage procedure

• Blood gas analysis: PaO2/FiO2 ratio < 300 in severely ill patients

• BMP: AKI, electrolyte derangements in patients with severe disease

• PT/INR: coagulopathy in patients with severe disease

• Consider serum lipase levels to assess for concurrent biliary pancreatitis in patients with suspected common bile duct obstruction.

Atypical presentations are common in elderly patients. Consider obtaining liver chemistries to evaluate for acute cholangitis in acutely ill elderly patients with nonspecific symptoms.

Acute cholangitis cannot be diagnosed with imaging alone. The goal of imaging is to evaluate for biliary obstruction that may have precipitated cholangitis.

• Indication: preferred first-line imaging modality in patients presenting with suspected cholangitis

• Supportive findings

  • Dilated common bile duct

  • Dilated intrahepatic bile ducts: indicates obstructive cholestasis

  • Thickened bile duct walls

  • Evidence of underlying etiology, such as:

    • Choledocholithiasis: occluding CBD stone with/without cholelithiasis may be visualized

    • Biliary stricture: focal narrowing of the bile duct(s), with dilation of the proximal biliary tree

    • Biliary tumor: intraluminal mass within the bile duct

• Indications

  • Confirmatory imaging modality if ultrasound is inconclusive

  • To rule out differential diagnoses if the clinical diagnosis is unclear

• Supportive findings

  • Concentric thickening and heterogeneous enhancement of the walls of the biliary tree

  • Bile duct dilation

  • Periductal edema

  • Evidence of underlying cause: choledocholithiasis, biliary tumor , biliary-enteric fistula, hydatid cyst, etc.

  • Evidence of complications: pericholecystic or liver abscess, portal vein thrombosis.

• Indication: an alternative confirmatory imaging modality if ultrasound is inconclusive

• Supportive findings: similar to CT findings

• Acute calculus cholecystitis or its complications

• Acalculous cholecystitis

• Liver abscess

• Acute hepatitis

• Bile leak (iatrogenic, e.g., post-ERCP, postcholecystectomy)

• Acute necrotizing pancreatitis

• Malignancy

  • HCC

  • Gall bladder cancer

  • Cholangiocarcinoma

  • Carcinoma head of the pancreas

  • Metastatic cancer