Cholangitis: Etiology, Clinical Presentation, and Management

Cholangitis is biliary tract infection secondary to obstruction. Classic Charcot's triad: fever, RUQ pain, jaundice. Reynolds' pentad adds hypotension and AMS (severe).

Etiologies

1. Choledocholithiasis (most common): Stones obstruct CBD.
2. Malignant obstruction: Pancreatic, cholangiocarcinoma, ampullary, metastatic.
3. Benign strictures: Post-cholecystectomy, PSC, chronic pancreatitis.
4. Parasites: Ascaris, Clonorchis, Opisthorchis.
5. Primary Sclerosing Cholangitis (PSC): Autoimmune, IBD-associated.
6. Recurrent pyogenic cholangitis: Asian endemic; pigment stones, strictures.
7. Iatrogenic: ERCP, stent occlusion.

Pathogens

Enteric flora: E. coli, Klebsiella, Enterococcus, Bacteroides, Enterobacter. Often polymicrobial.

Management

• Resuscitation: Fluids, broad-spectrum IV antibiotics (piperacillin-tazobactam, meropenem, or ceftriaxone + metronidazole).
• Biliary Decompression (Urgent/24h): ERCP ± sphincterotomy/stent; PTC if ERCP fails; surgical if necessary.
• Definitive Treatment: Cholecystectomy (if stones), stricture dilation, tumor resection/stenting.

Mortality 5–10% (higher with Reynolds' pentad). Early ERCP saves lives.