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March 2012
Cholangitis:Buzz for Emergency Care
Dr Usha Srinivas
Inflammation of the bile duct is known as cholangitis. The term applies to inflammation of any portion of the bile duct, which carries bile from the liver to the gall bladder and intestine. The inflammation is produced by bacterial infection or sometimes by other causes

The Digestive Process
Bile, which is needed for digestion, is produced in the liver and then enters the common bile duct (CBD). The bile accumulates in the CBD in between meals and during eating, the gall bladder contracts and the sphincter between the gall bladder and intestine relaxes, permitting bile to flow into the intestine and aid in digestion.

Bile is bacteria free when it is produced. A small number of bacteria may enter the bile duct and gall bladder from the intestine, but due to normal bile juice flow, the organisms are unable to multiply. The bile duct gets infected when the passage of bile out of the duct is blocked and the few bacteria that are there rapidly reproduce.

Causes of Bile Duct Blockage
  • Common bile duct [CBD] stones
  • Tumours
  • Strictures, which may be malignant or benign. These may occur due to repeated passage of stones, or injury after surgery. A stone from the gall bladder blocks the duct, and also allows bacteria to flow back into the CBD, and creates ideal conditions for their growth. Tumours on the other hand cause a more complete blockage of bile flow, both in and out, so fewer infections occur. The reproducing organisms are often able to enter the bloodstream and infect multiple organs such as the liver and heart valves.
  • Another source of inflammation of the bile duct occurs in diseases of altered immunity, known as autoimmune diseases. Primary sclerosing cholangitis is a typical example of an autoimmune disease involving the bile duct.
  • In tropical countries roundworm infestation and subsequent migration of the worms into the bile duct causes cholangitis. Many patients have been reported from Kashmir, India.
  • Liver flukes also can cause biliary infections.
Diagnosis and Treatment
Early diagnosis and treatment are very important, as cholangitis is a medical emergency. Patients need to be hospitalized, given intravenous fluids, and parenteral antibiotics
  • Blood cultures are sent to identify the organisms to exhibit the appropriate
  • Ultra sonogram is done to confirm the CBD obstruction.
  • Endoscopic retrograde cholangiography (ERCP) is done to identify the possible cause of biliary obstruction along with stone extraction and stent placement.
  • Strictures can also be stented.
  • Per-cutaneous methods of drainage may also be required.
  • After the condition of patient is stabilised, definitive treatment for the cause of obstruction is administered, with further imaging studies like MRCP or CT. In certain conditions surgery may be indicated.
Symptoms of Cholangitis
  • Severe abdominal pain, in the right upper quadrant associated with high-grade fever and chills.
  • Clay coloured stools, dark urine, nausea and vomiting.
  • Yellowish discolouration of the skin (jaundice) may be intermittent, due
    to obstruction to passage of bile
Dr Usha Srinivas is Sr consultant, Gastroenterology Apollo Hospitals, Chennai

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