Cholangitis natural history, complications and prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2],Farwa Haideri [3]

Patients who show early signs of multiple organ failure (renal failure, disseminated intravascular coagulation, alterations in the level of consciousness, and shock) or evidence of acute cholangitis, as well as those who do not respond to conservative treatment, should receive systemic antibiotics and undergo emergent biliary drainage. Unless early and appropriate biliary drainage is performed and systemic antibiotics are administered, death will occur. The prognosis is usually good with treatment but poor without treatment.

Acute cholangitis is the result of a bacterial infection that causes partial or complete obstruction of the biliary system. Patients with the disease present with a wide range of severity, from low-grade fever to severe sepsis. Patients usually present with Charcot’s triad which comprises of fever, abdominal pain and jaundice. Shock in the presence of pus within the biliary tree is indicative of acute suppurative cholangitis. Patients present with Reynold’s pentad that includes sepsis and mental confusion in addition to fever, abdominal pain and jaundice.^[1] A history of biliary disease, such as gallstones, previous biliary procedures, or the placement of a biliary stent are factors that are very helpful in understanding the natural history of cholangitis.^[2]

Complications related to cholangitis include:^[3][4][5]

• Renal failure
• Respiratory failure
  • The inability of the respiratory system to oxygenate blood and/or eliminate carbon dioxide
• Cardiac arrhythmia
• Wound infection
• Pneumonia
• Gastrointestinal bleeding
• Myocardial ischemia
• Acute cholecystitis
• Jaundice
• Pancreatitis

The risk of developing complications increased in subsequent years after gallbladder stones were first discovered, but have been decreasing since. Every year, 6-8% of patients whose symptoms progress from minor to serious undergo cholecystectomy. Fortunately, this percentage has been decreasing yearly.^[4][5]

• Acute cholangitis bears a significant risk of death, with the leading cause being irreversible shock with multiple organ failure (which could have multiple possible complications of severe infections). Modern improvements in diagnosis and treatment have led to a reduction in mortality.
• Before 1980, the mortality rate was greater than 50%; in the past thirty years, it has decreased to 10-30%. ^[6][7][8] These differences in mortality can likely be attributed to improvements in early diagnosis and supportive treatment.
• Patients with signs of multiple organ failure are likely to die unless they undergo early biliary drainage and treatment with systemic antibiotics. Other causes of death following severe cholangitis include heart failure and pneumonia.^[3][4][5]

• Prognosis is good in patients who have quick and adequate drainage where there is improvement in hemodynamic and inflammatory parameters.^[9]
• Poor outcomes are seen if urgent surgery is required for drainage.^[5][10]

• The prognosis is poor if the following five factors are present:^[5][10]
  1. High fever
  2. Elderly patient
  3. Hyperbilirubinemia
  4. Leukocytosis
  5. Hypoalbuminemia

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