Acute cholangitis is caused by infection of an obstructed biliary tree, with the obstruction usually secondary to choledocholithiasis. Cholangitis is less common with a malignant obstruction. Occasionally acute cholangitis develops in a setting of bile duct sludge, with sludge presumably leading to intermittent obstruction. An association probably exists between a peri-Vaterian diverticulum and cholangitis. The risk for cholangitis is increased if the common bile duct drains directly into the diverticulum. Distal duodenal obstruction more often results in pancreatitis rather than cholangitis.  Typically eosinophilic gastroenteritis involves the stomach and small bowel, although eosinophilic cholangitis also exists. When extensive, imaging reveals marked bile duct wall thickening and lumen narrowing.
this is radiology images of Obstructed afferent loop (arrow) causing cholangitis.
Infection Pyogenic, Most pyogenic cholangitis develops in a setting of choledocholithiasis and, less often, strictures. An occasional patient forms recurrent stones and develops multiple episodes of ascending cholangitis. The bile ducts dilate and bile stasis is evident. Complications include liver abscess and portal vein thrombosis. Focal or generalized bile duct dilation and strictures are the only consistent imaging finding in pyogenic cholangitis, although many of these patients also have bile duct stones and biliary obstruction. The bile duct wall is thickened and inflamed, identified by CT and MR as increased postcontrast enhancement. Often focal liver enhancement is also evident. Computed tomography reveals liver inflammatory pseudotumors in some patients with pyogenic cholangitis, consisting of illdefined and hypodense regions; early arterial phase images reveal nodular or wedge-shaped inhomogeneous enhancement, presumably due to chronic inflammation. Postcontrast, a central hypodense region is believed to represent chronic inflammation, while septa are secondary to fibroblastic proliferation.
An MRCP in recurrent pyogenic cholangitis is able to outline major bile ducts and thus is often superior to direct cholangiography. In one study,MRCP depicted all dilated segments, 96% of duct strictures, and 98% of segments containing calculi; direct cholangiography, on the other hand, depicted only about half the dilated segments, ductal strictures, and calculi. In some institutions the initial therapy for acute cholangitis consists of antibiotics and general supportive therapy. With a poor response, especially in a high surgical risk patient, endoscopic or percutaneous biliary drainage is performed to bypass an obstruction.
Others believe that early endoscopic biliary drainage is warranted in these patients, and endoscopic drainage should be performed on an urgent basis. In severe cholangitis, endoscopic biliary drainage is associated with a lower morbidity and mortality than with surgical decompression. Percutaneous transhepatic drainage or surgical drainage is a viable option if endoscopic drainage cannot be performed.
In general, prolonged interventional procedures during the acute phase are associated with increased complications. Excessive catheter manipulation should be avoided, with the aim being to place a biliary drainage catheter proximal to the obstruction. Yearly surveillance ERCP has been proposed for patients with recurrent bile duct stones who are prone to developing episodes of acute cholangitis; stone removal decreases risk of cholangitis.
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