Cholangitis

Dr. med. Julia Schwarz is a freelance writer in the medical department.

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Cholangitis (inflammation of the bile duct) is inflammation of the bile ducts inside or outside the liver. The typical symptoms of cholangitis are fever, upper abdominal pain, and yellowing of the skin (jaundice). It is a rarer disease that affects women over the age of 40 in particular. Cholangitis is mostly caused by bacteria or gallstones. It can be treated well with antibiotics or gallstone removal. Here you can read everything you need to know about cholangitis.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. K74K83K80

Cholangitis: description

Cholangitis (inflammation of the bile duct) is an inflammation of the bile ducts that connect the gallbladder to the small intestine. The bile is formed by the liver cells and thickened and stored in the gallbladder. When eating, the bile is increasingly released to the duodenum via the bile ducts. The bile acids it contains are required in the intestine to break down and digest the fats absorbed through food. In addition, toxic substances are released from the body via the liver and the biliary tract into the intestine and excreted with the stool.

Acute cholangitis

About 15 percent of the population suffer from gallstones (cholelithiasis), which can hinder the outflow of bile. This increases the risk of local bacterial colonization. This can lead to a purulent inflammation of the biliary tract (cholangitis). Since overweight women above the age of 40 have an increased risk of gallstones, they are twice more likely to develop cholangitis than men.

Primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a special form of bile duct inflammation and is one of the autoimmune diseases. It is a chronically progressive inflammation of the biliary tract inside and outside the liver. The disease is closely related to other autoimmune diseases such as inflammatory bowel disease ulcerative colitis. The PSC leads to scarring (sclerosis) of the biliary tract up to biliary congestion (cholestasis). In the later stages, people often develop cirrhosis of the liver, which can only be treated with a liver transplant.

Cholangitis: symptoms

Bacterial cholangitis and primary sclerosing cholangitis have some similarities in terms of symptoms:

Acute (bacterial) cholangitis: symptoms

The typical symptoms of cholangitis here are severe pain in the right upper abdomen, which is described as constant and constant. Those affected also often suffer from a fever of over 40 degrees Celsius and a pronounced feeling of illness. Cholangitis also leads to yellowing of the skin (jaundice) in many patients after a few days. The yellowing of the skin is caused by the backflow of bile into the liver. The breakdown product (bilirubin) of the red blood pigment (hemoglobin) can no longer be excreted in the bile, passes into the blood and is deposited in the skin and mucous membranes. The yellowing of the skin (jaundice) can be accompanied by severe itching.

Primary sclerosing cholangitis: symptoms

Patients with primary sclerosing cholangitis also suffer from yellowing of the skin, which in most cases is also accompanied by excruciating itching. In 80 percent of the cases, the patients also have a chronic inflammatory bowel disease (ulcerative colitis). The risk of bacterial inflammation of the biliary tract is increased with PSC. Such bacterial cholangitis can come on in flares. It triggers the typical symptoms such as fever, upper abdominal pain and a feeling of weakness.

Cholangitis: causes and risk factors

Acute cholangitis and primary sclerosing cholangitis have very different causes:

Acute cholangitis due to intestinal bacteria

Acute cholangitis is often caused by intestinal bacteria that migrate from the small intestine via the main bile duct (ductus choledochus) into the gall bladder and the bile duct system. The main bile duct, together with the duct of the pancreas (ductus pancreaticus), flows into the duodenum at the father's papilla. The opening of the common duct is regulated by a sphincter muscle. Even if the sphincter muscle usually prevents the intestinal bacteria from ascending into the liver, this can still happen and subsequently lead to cholangitis.

Acute cholangitis caused by gallstones (cholelithiasis)

Gallstones are usually caused by high cholesterol in the bile. Overweight women over the age of 40 are particularly at risk and often have gallstones. The gallstones can migrate from the gallbladder into the biliary tract system and block the biliary tract, whereupon the bile secretion backs up - sometimes as far as the liver. The standing secretion cannot drain off properly and bacteria can multiply more easily. Similar to standing water in nature, if there is insufficient drainage, an imbalance between the bacteria is more likely to arise. The bile duct mucosa is then irritated and a purulent inflammation (cholangitis) spreads faster.

Primary sclerosing cholangitis (PSC): autoimmune disease

Primary sclerosing cholangitis (PSC) is a special form of cholangitis that is based on an autoimmune inflammatory process. The bile ducts of those affected are chronically inflamed and narrow in the course at irregular intervals. The constrictions affect the bile ducts inside and outside the liver and can lead to a build-up of bile with attacks of inflammation.

The PSC often occurs in the context of a chronic inflammatory bowel disease (ulcerative colitis). If, in addition to the symptoms typical of cholangitis, slimy, bloody diarrhea also appears, a PSC must always be considered.

Cholangitis: examinations and diagnosis

The right person to contact if you suspect cholangitis is a specialist in internal medicine or gastroenterology. The doctor will inquire about your current symptoms in an initial conversation and ask you to describe the course of the symptoms and any previous illnesses (anamnesis). The doctor may ask you the following questions:

• Do you suffer from stomach ache?
• Is the abdominal pain crampy or persistent?
• Do you have fever?
• Do you have any known inflammatory bowel disease (ulcerative colitis)?
• Have you ever had gallstones?

The doctor will then perform a physical examination, first of all taking a closer look at your skin. Any yellowing of the skin or so-called liver skin signs indicate liver damage. Liver skin signs are typical skin changes that occur in chronic liver diseases such as star-shaped enlargements of skin vessels (spider naevi), reddening of the palms of the hands (palma erythema) and shiny red, smooth lips (lacquer lips).

The doctor will then listen to your stomach with a stethoscope to check for bowel sounds and the air and stool levels in the bowels. Then the doctor will palpate your stomach. The doctor often presses under the right costal arch and asks the patient to take a deep breath. If the pain intensifies and inhalation is stopped, the suspicion of an inflamed gallbladder (cholecystitis) is reinforced.

Since the physical examination can only partially prove cholangitis, further examinations usually follow:

Blood test

If you have cholangitis, your doctor can use a blood test to detect signs of inflammation. Elevated values ​​for the so-called C-reactive protein (CRP) and the white blood cells (leukocytes) indicate a bacterial inflammation. However, these inflammatory parameters in the blood are not specific to cholangitis, but can also occur in the context of other inflammatory reactions in the body.

Ultrasound (sonography)

The ultrasound examination of the abdomen (abdominal sonography) can already give the first clues as to the cause of cholangitis. Expanded bile ducts can indicate a bile congestion. If there are gallstones in the bile duct system, they usually form in the gallbladder and are best represented there.

Endoscopic retrograde cholangiopancreatography (ERCP)

If cholangitis or gallstones in the bile duct system are suspected, which are preventing the bile from draining, endoscopic retrograde cholangio-pancreatography (ERCP) is a reliable diagnostic tool. The ERCP enables the biliary tract to be visualized from within. A thin tube is pushed through the esophagus and the stomach into the duodenum, through which X-ray contrast medium is injected into the common duct of the bile and pancreas. Then the bile duct system is x-rayed with the help of an X-ray machine. If gallstones can be detected, they can be removed directly by the ERCP in the same session (stone extraction by papillotomy).

Cholangitis: treatment

Therapy for cholangitis depends on the cause of the disease.

Bacterial cholangitis

Acute bile duct inflammation (cholangitis) is usually triggered by bacteria. The doctor then usually prescribes high-dose antibiotics for the patient. The active ingredient group of fluoroquinolones is used particularly frequently. In some cases, a combination of two different antibiotic active ingredient groups is used in order to cover a larger spectrum of germs (broad-spectrum antibiosis).

Cholangitis patients should not eat anything for at least 24 hours so that digestion and thereby the flow of bile are not promoted. In addition, patients are given pain relievers (such as metamizole) and antipyretic drugs (such as paracetamol and ibuprofen). The pain usually subsides after a few days. Patients should also take care to drink enough fluids.

Gallstone removal

If the cholangitis is due to a blockage of the bile ducts with gallstones, these must be removed immediately. As part of an endoscopic retrograde cholangio-pancreatography (ERCP), the bile ducts can be precisely assessed and gallstones removed. If the removal of the gallstones does not improve the symptoms, a so-called stent (tube) can be inserted into the bile duct. The tube keeps the bile duct open and thus improves the outflow of bile into the small intestine.

Gallstones mainly form in the gallbladder and can migrate from there into the bile duct system. After an acute flare-up of inflammation, the gallbladder is usually surgically removed (cholecystectomy).

Primary sclerosing cholangitis

Primary sclerosing cholangitis is an autoimmune disease and the cause cannot be treated so far. The patients with jaundice (jaundice) often suffer from severe itching. The medicinal excretion of bile acids is therapeutically in the foreground. The drug ursodeoxycholic acid helps dissolve the cholesterol-containing gallstones. In the case of acute flare-ups, antibiotics are also used in PSC. In the course of PSC, scarring of the entire liver tissue (cirrhosis of the liver) can develop. The last treatment option (ultima ratio) is then a liver transplant.

Cholangitis: disease course and prognosis

If the cholangitis heals and any gallstones are removed, the prognosis for biliary inflammation is very good. Most patients then have a one-time illness. Renewed flare-ups (relapses) are found in PSC, but are otherwise rather rare.

Acute bacterial cholangitis should always be treated immediately with antibiotics so that the bacteria do not spread throughout the body via the bloodstream and lead to blood poisoning (cholangiosepsis). In the advanced stages, the bile duct inflammation can spread to the rest of the liver tissue and cause purulent abscesses.

The longer the cholangitis persists, the higher the risk of narrowing (strictures) and scarring of the biliary tract. Narrowing of the biliary tract prevents the unrestricted outflow of bile and increases the risk of biliary backlog. PSC is also associated with an increased risk of liver cirrhosis and bile duct cancer (cholangiocellular carcinoma).

The life expectancy of PSC patients is reduced, while acute cholangitis is not associated with a reduction in life expectancy.

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