Ascending Cholangitis: Pathogenesis and clinical findings
Authors: Brandon Hisey, Neel Mistry Reviewers: Alec Campbell, Vina Fan, Ben Campbell, Kelly Burak*, Eldon Shaffer* * MD at time of publication
Reflux of biliary contents into the vascular system (cholangiovenous reflux)
Bacteria ascends into biliary tract from duodenum via Sphincter of Oddi
Gallstone in the common bile duct
Stricture of biliary/hepatic ducts
Biliary / pancreatic duct malignancy
Biliary obstruction (partial bile duct obstruction)
↓ Excretion of bilirubin into
bileà ↑ bilirubin in blood
↑ Serum bilirubin
Deposition of bilirubin in the skin and mucous membranes
Jaundice*†
Parasites in bile duct
(E.g. Clonorchis)
Complication of endoscopic retrograde cholangiopancreatography (ERCP)
Bile accumulates in biliary tract
Bile duct dilation on ultrasound
Sludge (bile precipitants) impact bile ducts worsening obstruction
Obstruction & detergents in bile inflame ductal mucosa. Inflammation then spreads to adjacent structures
Stimulates phrenic (C3-C5) and foregut autonomic nerves (T5-T8)
Dull right upper quadrant pain*† radiating to back and right shoulder
↑ Intra-biliary pressure
Impaired forward flowà
↑ backflow of bile
Impaired bile secretion damages ductal epithelium of the biliary tract
Damaged ductal epithelium leaks ALP and GGT (enzymes) into blood
↑ Serum ALP and GGT
↑ Permeability of bile ductules
Reduced flushing of bile out to duodenum
Inflammatory response triggered
Fever*† ↑ WBCs
Tachycardia Hypotension† Confusion† Oliguria
Bacterial translocation from biliary tract into blood
Bacteremia
Massive systemic inflammatory response
Septic Shock
(see Distributive Shock slide)
* Charcot’s triad ~20% of cases | † Reynolds’ pentad ~7% of cases
Legend:
Pathophysiology
Mechanism
Sign/Symptom/Lab Finding
Complications
First published November 18, 2015; Updated August 31, 2022 on www.thecalgaryguide.com