Ascending cholangitis

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With ascending cholangitis, “cholang-” refers to the bile ducts and “-itis” refers to inflammation which is usually caused by a bacterial infection.
These bacteria are normally found in the intestines and work their way up the bile ducts from the duodenum of the small intestine, so that’s why it’s known as ascending cholangitis, also sometimes acute cholangitis because it can happen over a relatively short period of time.
Normally bacteria from the gut has a pretty tough time ascending up the bile ducts, and this is because bile flows down from the gallbladder, along with some pancreatic juice from the pancreas, into the duodenum, and this tends to flush out any bacteria trying to sneak their way up.
In ascending cholangitis this flow of bile is often blocked, and one common reason is choledocholithiasis, which refers to gallstones in the common bile duct.
In choledocholithiasis, gallstones form in the gallbladder and occasionally slip out, travel through the cystic bile duct, and then lodge into the common bile duct, obstructing the normal flow of bile.
These gallstones are typically made up of bile components, and risk factors for developing them include things like female sex, obesity, pregnancy, and age, sometimes remembered by the 4 F’s—female, fat, fertile, and forty.
Other, less common causes include things that cause stricture, or narrowing of the bile ducts—like a nearby cancerous growth, which can compress the duct as the tumor slowly enlarges, or injury experienced during a laparoscopic procedure.
Once the flow of bile is blocked, bacteria can slowly make their way up the ducts and colonize the biliary system without the risk of being washed away.
Most commonly the bacterial species involved are a mixture of enteric organisms including common ones like E coli, Klebsiella species, and Enterococcus species.
These bacteria can migrate up to the blockage and continue to infect the stagnant bile as well as the surrounding tissue.
Also, since the bile duct is under high pressures from the obstruction, it can cause the spaces between the cells lining the ducts to widen, which allows the bacteria and the bile direct access to the bloodstream.
Now, a bacterial infection around the bile ducts can cause fevers and right upper quadrant abdominal pain, and if bile starts to back up into the bloodstream, individuals might also have jaundice.
But if these bacteria get into the bloodstream, then it can lead to septic shock - which is where the blood vessels become leaky, causing hypotension, which can reduce bloodflow to various organs like the brain, which causes confusion.
A common categorization of these symptoms is Charcot’s triad which includes fever, right upper quadrant pain, and jaundice as well as another one called Reynold’s pentad which includes those three plus hypotension and confusion.
For diagnosis, blood tests that assess for evidence of infection, jaundice, and shock, as well as with medical imaging like ultrasound as well as endoscopic retrograde cholangiopancreatography (or ERCP), which is where an endoscope is inserted down the esophagus and a radiocontrast dye is injected into the bile ducts, allowing visualization of any blockages on X-ray.
Treatment typically involves managing the symptoms, like offering rehydration and starting antibiotics. To definitively treat ascending cholangitis, though, the obstruction has to be removed, which can also done using ERCP, where it can suction out the gallstone.
For larger gallstones, shockwave lithotripsy might be used, which uses high frequency sound waves from outside the body to break down the stone.
Also, especially in the case of stricture, the bile ducts can be widened with a stent. Finally, if gallstones are the underlying cause, a cholecystectomy, or removal of the gallbladder, is typically recommended to avoid future gallstone-related complications.
Alright, as a quick recap, ascending cholangitis is a bacterial infection of the common bile duct, most often caused by a gallstone lodged in the bile ducts, which allows bacteria to infect the ducts, and potentially gain access to the blood stream.
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