Cholangitis differential diagnosis

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


Cholangitis must be differentiated from other causes of infection in the common bile duct, as well as inflammation and infection of the gall bladder.and mainly from other causes of acute abdomen.

Differentiating Cholangitis from other Diseases

Cholangitis should be differentiated from the following:[1]

Differentiating acute cholangitis from other causes of abdominal pain

The differential diagnosis of diseases presenting with abdominal pain, fever and jaundice are discussed below.

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-


Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute suppurative cholangitis RUQ + + + + + + + N
  • Abnormal LFT
  • WBC >10,000
  • Ultrasound shows biliary dilatation/stents/tumor
  • Septic shock occurs with features of SIRS
Acute cholangitis RUQ + + N
  • Ultrasound shows biliary dilatation/stents/tumor
  • Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis RUQ + + + Hypoactive Ultrasound shows:
  • Gallstone
  • Inflammation
Acute pancreatitis Epigastric + + ± + ± N
  • Ultrasound shows evidence of inflammation
  • CT scan shows severity of pancreatitis
  • Pain radiation to back
Primary sclerosing cholangitis RUQ + + N ERCP and MRCP shows
  • Multiple segmental strictures
  • Mural irregularities
  • Biliary dilatation and diverticula
  • Distortion of biliary tree
  • The risk of cholangiocarcinoma in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
Cholelithiasis RUQ/Epigastric ± ± ± Normal to hyperactive for dislodged stone
  • Fatty food intolerance
Gastric causes Gastrointestinal perforation Diffuse + ± - ± + + + ± Hyperactive/hypoactive
  • WBC> 10,000
Intestinal causes Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-


Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Inflammatory bowel disease Diffuse ± ± + + + Normal or hyperactive

Extra intestinal findings:

Whipple's disease Diffuse ± ± + + ± N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Hepatic causes Viral hepatitis RUQ + + + Positive in Hep A and E + Positive in fulminant hepatitis Positive in acute + N
  • Abnormal LFTs
  • Viral serology
  • US
  • Hep A and E have fecal-oral route of transmission
  • Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + + ± + + + ± Normal or hypoactive
  • US
  • CT
Hepatocellular carcinoma/Metastasis RUQ + + +
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy

Other symptoms:

Budd-Chiari syndrome RUQ ± ± Positive in liver failure leading to varices N
Findings on CT scan suggestive of Budd-Chiari syndrome include:
Ascitic fluid examination shows:
Peritoneal causes Spontaneous bacterial peritonitis Diffuse + Positive in cirrhotic patients + ± + + Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
  • Ultrasound for evaluation of liver cirrhosis
Hollow Viscous Obstruction Biliary colic RUQ + + N
  • Ultrasound


  1. Miura F, Takada T, Kawarada Y, Nimura Y, Wada K, Hirota M, Nagino M, Tsuyuguchi T, Mayumi T, Yoshida M, Strasberg SM, Pitt HA, Belghiti J, de Santibanes E, Gadacz TR, Gouma DJ, Fan ST, Chen MF, Padbury RT, Bornman PC, Kim SW, Liau KH, Belli G, Dervenis C (2007). "Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg. 14 (1): 27–34. doi:10.1007/s00534-006-1153-x. PMC 2784508. PMID 17252294.

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