Ascending cholangitis is a severe, acute infection and inflammation of the biliary tree, often resulting from a blockage that facilitates bacterial ascent from the duodenum

Aetiology

Primary causes include:

• Biliary calculi (stones) - accounting for approximately 50% of cases
• Benign biliary stricture - 20% of cases, these can be congenital, post-infectious, or due to an inflammatory process
• Malignancy - 10-20%, this can originate from the gallbladder, bile duct, ampulla, duodenum, or pancreas

Clinical features

• Patients with ascending cholangitis often present with Charcot's triad, which is observed in around one-third of patients:
  • Right upper quadrant pain
  • Fever
  • Jaundice
• In severe cases, two additional symptoms may present, forming Reynold's pentad:
  • Hypotension
  • Mental confusion

Investigations

• Bloods: raised LFTs and inflammatory markers
• Ultrasound: abdo ultrasound can detect bile duct dilatation but may not reliably identify stones in the mid/distal biliary duct
• CT: provides a detailed anatomical view of the biliary tree and may visualise radiopaque stones
  • However, it is less effective at viewing radiolucent cholesterol stones, which are more common
• MRCP: offers the highest accuracy in determining the disease, including detection of gallstones or strictures, and visualizes nearly all causes of biliary tree obstruction
• ERCP: may be used therapeutically once the aetiology has been determined

Management

• Resuscitation with intravenous fluids and antibiotics
• Biliary drainage, which can be performed via:
  • Endoscopic drainage - ERCP, potentially with stent placement for strictures
  • Percutaneous drainage - percutaneous transhepatic cholangiography (PTC)
  • Surgical drainage
• Assessment and management of the underlying cause e.g. gallstones may necessitate a cholecystectomy, further investigations/management of a malignant stricture