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Essentials of Diagnosis
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Often a history of biliary pain, which may be accompanied by jaundice
Occasional patients present with painless jaundice
Nausea and vomiting
Cholangitis should be suspected with fever, which may be followed by hypothermia, jaundice, leukocytosis and gram-negative shock
Stones in common bile duct most reliably detected by endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasonography
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General Considerations
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Bile duct stones usually originate in the gallbladder but may also form spontaneously in the common bile duct after cholecystectomy
Symptoms, including those of cholangitis, result if there is obstruction
Biliary pain results from rapid increases in bile duct pressure due to obstructed bile flow
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About 15% of patients with gallstones have choledocholithiasis (common bile duct stones)
The percentage rises with age, and the frequency in elderly people with gallstones may be as high as 50%
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See Table 16–9
Biliary pain with jaundice in choledocholithiasis
Frequently recurring attacks of right upper abdominal pain that is severe and persists for hours
Chills and fever associated with severe pain in acute cholangitis
Charcot triad (pain, fever [and chills], and jaundice) is characteristic of acute cholangitis
Additional symptoms of altered mental status and hypotension (Reynold pentad) signifies acute suppurative cholangitis and is an endoscopic or surgical emergency
According to the Tokyo guidelines, either of the following needs to be present to establish the diagnosis of acute cholangitis:
The full Charcot triad or
Two elements of the Charcot triad plus laboratory evidence of an inflammatory response (eg, elevated WBC count, C-reactive protein), elevated liver test results, and imaging evidence of biliary dilatation or a cause of obstruction
Hepatomegaly may be present in calculous biliary obstruction, and tenderness is usually present in the right upper quadrant and epigastrium
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