Acute Cholangitis & Choledocholithiasis

In this audio, we will discuss acute cholangitis and choledocholithiasis, focusing on key diagnostic criteria, treatment options, and management strategies.

AudioBoards is an audio-learning platform designed to help you review key topics and clinical vignettes while on the move. With the convenience of headphones, you can listen and learn as you go about your day—whether doing household chores, running errands or during your daily workout. This platform lets you make the most of small pockets of time, transforming mundane tasks into valuable learning opportunities.

Elevate your internal medicine knowledge without letting a busy schedule hold you back. Try AudioBoards today and enhance your ability to retain important information—one audio lesson at a time.

Our goal is to enhance understanding of medical principles while emphasizing that this content is for informational purposes only and not a substitute for professional clinical guidance. Tune in to expand your medical knowledge and stay informed about current trends in medicine!

Transcript

 "Welcome to today’s episode of AudioBoards. In this session, we’re discussing Acute Cholangitis and Choledocholithiasis. These diseases often present with overlapping symptoms, which makes early diagnosis and prompt treatment essential for optimal outcomes. Let’s dive in."

"To begin with,acute cholangitis is a severe bacterial infection of the biliary tree, which occurs when there’s obstruction and bile stasis, often caused by gallstones, tumors, or biliary strictures. The infection typically arises from bacteria migrating retrogradely from the gut into the bile duct, which triggers an immune response and results in inflammation. If left untreated, this can lead to sepsis."

"Clinically,Charcot’s triad is the classic presentation of acute cholangitis, which includes fever, jaundice, and right upper quadrant pain. In more severe cases, patients may present with Reynolds’ pentad, which adds hypotension and altered mental status—signs that indicate septic shock. However, in older adults, cholangitis can present with more subtle symptoms, such as confusion, which can complicate diagnosis in this population."

"To diagnose acute cholangitis, we rely on the Tokyo Guidelinesfrom 2018. These guidelines suggest looking for signs of inflammation, cholestasis, and imaging findings. Inflammatory markers like fever, an elevated white blood cell count, and C-reactive protein are key indicators. Cholestasis is characterized by jaundice, elevated bilirubin levels, and increased liver enzymes. Imaging, such as ultrasound, may reveal biliary dilation or the underlying cause—such as choledocholithiasis or a biliary stricture. The diagnostic criteria are clear: to make a definitive diagnosis, one marker from each of the three categories is required. A suspected diagnosis requires at least one marker from systemic inflammation and one from either cholestasis or imaging."

"In terms of laboratory testing, key labs include a CBC, liver function tests, CRP, and blood cultures. If possible, bile cultures may also be helpful. To assess the severity of the disease, several additional tests are used. Anarterial blood gas can evaluate oxygenation status—particularly a Pao2 to Fio2 ratio under 300, which indicates severe disease. The basic metabolic panel helps assess for acute kidney injury or electrolyte disturbances, and PT/INRcan check for coagulation abnormalities, which are common in severe cases."

"In some cases, serum lipase may be measured to rule out concurrent biliary pancreatitis. When imaging is needed, aright upper quadrant ultrasound is often the first choice. If ultrasound findings are inconclusive or suspicion remains high, a CT scan with IV contrast or an MRCP might be required to identify the cause of the obstruction."

"Cholangitis severity is classified into three grades:

Grade 1 (Mild), where there is no organ dysfunction.

Grade 2 (Moderate), where there are two of the following: a white blood cell count over 12,000 or below 4,000, age over 75, bilirubin greater than 5 mg per dL, or serum albumin less than 70% of normal.

Grade 3 (Severe), which includes any organ dysfunction, such as hypotension requiring pressors, acute respiratory distress syndrome, acute kidney injury, or low platelet count."

"Now, let’s discuss the treatment. For patients with acute cholangitis, fluid resuscitation and broad-spectrum empiric antibiotics are essential for stabilization.Biliary drainage is critical in severe cases or when sepsis is present. This can be done via ERCP, endoscopic ultrasound, or surgical drainage. ERCPis considered the gold standard for biliary decompression. For milder cases, biliary decompression can be delayed until after initial medical therapy. Patients should be kept NPO and may require an NG tube for decompression. NSAIDs are often used for pain management during this time."

"Let’s now turn to choledocholithiasis, which refers to the presence of gallstones in the common bile duct. These stones can either pass from the gallbladder into the bile duct or form within the duct itself, often due to conditions that cause biliary stasis, such as cystic fibrosis, total parenteral nutrition, or post-cholecystectomy."

"Symptoms typically include right upper quadrant pain, especially after eating, which can last for several hours. Patients may also experience signs of extrahepatic cholestasis, such as jaundice, pale stools, dark urine, and pruritus. If untreated, choledocholithiasis can lead to complications like cholecystitis, pancreatitis, and cholangitis."

"To evaluate choledocholithiasis, we start with aright upper quadrant ultrasoundto visualize stones or biliary dilation.Liver function testsare also performed to assess for cholestasis, with elevated bilirubin, GGT, and alkaline phosphatase being key markers. While ultrasound can suggest the presence of CBD stones, it’s not always definitive. "If there’s a high suspicion of choledocholithiasis, as evidenced by CBD stones on ultrasound, ERCPis the diagnostic and therapeutic procedure of choice. For intermediate likelihood cases,MRCPorendoscopic ultrasoundmay be performed."

"Treatment of choledocholithiasis depends on the patient’s clinical presentation. For symptomatic patients,ERCP with sphincterotomy and stone extractionis the procedure of choice. In cases where stones are too large for ERCP, lithotripsymay be used to fragment the stones. If biliary pancreatitis is present, ERCP is generally avoided unless cholangitis or bile duct obstruction is evident."

"After successful stone removal with ERCP,laparoscopic cholecystectomyis typically recommended to prevent recurrent biliary events. The timing of this surgery depends on the severity of the patient’s condition. For uncomplicated choledocholithiasis, cholecystectomy is often performed within 72 hours of successful ERCP. For patients with cholangitis, surgery is generally performed within six weeks."

That’s all for today’s episode. Thanks for listening to AudioBoards. Stay tuned for more educational content in our next episode!

"The views and opinions expressed on the AudioBoards Podcast do not necessarily reflect those of our employers. This podcast is for educational purposes only and should not be used to diagnose or treat any medical conditions. It is not a substitute for professional medical advice. Always consult a qualified, board-certified healthcare provider for any medical concerns."