Ascending cholangitis natural history, complications and prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anila Hussain, MD [2]

Overview

The severity of ascending cholangitis can range anywhere from mild to life-threatening and can be fatal if left untreated. Complications of acute cholangitis may include sepsis, hepatic abscesses, liver failure, renal failure, pancreatitis as well as postoperative complications like pneumonia, respiratory failure, heart failure, cardiac arrhythmias, cardiac ischemia, gastrointestinal bleeding, bile leaking into peritoneum or abdomen, renal abscess, fistulae, wound infection, wound dehiscence and disseminated intravascular coagulation (DIC). 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. Prognosis is good in patients who have quick and adequate drainage where there is an improvement in hemodynamic and inflammatory parameters. Prognosis of the disease depends on the severity of the illness. Poor outcomes are seen if urgent surgery is required for drainage

Natural History

Ascending Cholangitis, also known as acute cholangitis is a systemic disease caused by the inflammation and infection of the biliary tree most commonly following an obstruction in the biliary tract. It is characterized by a triad (Charcot's Triad) of fever, jaundice and right upper quadrant pain. A pentad (also known as Reynold's pentad) can also be seen in which altered mental status and sepsis are present in addition to usual findings. The severity of disease range anywhere from mild infection to life-threatening sepsis by the translocation of bacteria into the bloodstream. If left untreated, patients with ascending cholangitis may progress to develop severe sepsis and multiorgan failure leading to death

Complications

Some complications of ascending cholangitis include;

• Sepsis - Gram negative bacteremia
• Hepatic abcesses
• Liver failure
• Renal failure
• Pancreatitis

Other complications that are seen in ascending cholangitis patients can occur following the treatment . Post-operative complications may include;

• Pneumonia
• Respiratory failure
• Heart failure
• Cardiac arrythmias
• Cardiac ischemia
• Gastrointestinal bleeding
• Bile leaking into peritoneum or abdomen
• Renal abcess
• Fistulae
• Wound infection
• Wound dehiscence
• Disseminated intravascular coagulation (DIC)

Prognosis

• 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%; However, in the past thirty years, it has decreased to 10-30%.. Mortality rate after the year 2000 was found to be 2700-10,000 per 100,000. These differences in mortality can likely be attributed to improvements in early diagnosis and supportive treatment.
• Patients with signs of multiple organ failure have a high mortality risk and need urgent biliary drainage and treatment with systemic antibiotics. Other causes of death following severe cholangitis include heart failure and pneumonia.

• Prognosis is good in patients who have quick and adequate drainage where there is an improvement in hemodynamic and inflammatory parameters.

Prognosis of disease depends on the severity of the illness. Poor outcomes are seen if urgent surgery is required for drainage. Severe ascending cholangitis is associated with organ dysfunction in one or more organ as described below;

• Hypotension requiring dopamine ≥5 μg/kg per min, or any dose of nor-epinephrine
• Altered mental status or disturbance of consciousness
• Respiratory Compromise - PaO2/FiO2 ratio <300
• Renal dysfunction - Oliguria and serum creatinine >2.0 mg/dl
• Hepatic abnormalities with PT‐INR >1.5
• Hematological dysfuction - Platelet count <100,000/mm3

Other bad prognostic factor in addition to organ dysfuction include preexisting cirrhosis, hypoalbuminemia, Bilirubin > 90umol/L, thrombocytopenia, female sex and old age.