~ 601 ~ International Journal of Surgery Science 2020; 4(2): 601-604 E-ISSN: 2616-3470 P-ISSN: 2616-3462 © Surgery Science www.surgeryscience.com 2020; 4(2): 601-604 Received: 01-02-2020 Accepted: 05-03-2020 Dr. Ketan Vagholkar Professor, Department of Surgery, D.Y. Patil University School of Medicine, Navi Mumbai, Maharashtra, India Corresponding Author: Dr. Ketan Vagholkar Professor, Department of Surgery, D.Y. Patil University School of Medicine, Navi Mumbai, Maharashtra, India Acute cholangitis: Diagnosis and management Dr. Ketan Vagholkar DOI: https://doi.org/10.33545/surgery.2020.v4.i2g.447 Abstract Acute cholangitis is a serious septic condition of the biliary tract. It is associated with obstruction of the biliary passages. Early diagnosis and assessment of the severity is essential. Aggressive supportive care, commencement of appropriate antibiotics, optimizing the function of various vital organ systems and early biliary drainage are pivotal in reducing the morbidity and mortality associated with this condition. Keywords: Acute cholangitis diagnosis severity management Introduction Infections of the biliary tract are commonly encountered in surgical practice. Acute cholecystitis and acute cholangitis are the common biliary tract infections. The aetiology of acute cholangitis is variable ranging from stone disease to malignancy. Early diagnosis and prompt treatment is essential. The morbidity and mortality associated with acute cholangitis is quite high if diagnosis and treatment is delayed [1] . The aetiopathogenesis, diagnosis, severity assessment and management of acute cholangitis is discussed in the paper. Aetiopathogenesis Normal defence mechanisms in the biliary system preventing infection There are a multiple mechanisms which protect the biliary system from infection [1, 2, 3] . 1. Continuous normal free flow of bile in the biliary passages keeps the intraductal pressure low and flushes out the passages thereby preventing bacterial concentration. 2. Bile salts have bacteriostatic activity. 3. Biliary epithelium secretes IgA which is protective and also secretes mucus which has anti- adherent properties. 4. Kupffer cells in the biliary epithelium and tight junctions between the cholangiocytes prevent translocation of bacteria from the hepatobiliary system into the portal venous system. 5. The sphincter of Oddi prevents any migration of bacteria from the duodenum into the biliary system. In an obstructed system there is a rise in the intraductal pressure due to stagnation of bile. The tight junctions between the cholangiocytes widen leading to entry by bacteria. The function of the Kupffer cells is also altered accompanied by fall in Ig A levels. This leads to successful bacterial invasion of the biliary passages [3, 4] . The normal choledochal pressure is 7 to 14 cms of water. Complications develop when the pressure exceeds 25 cms of water. There is cholangiovenous and cholangiolymphatic reflux. Bacteraemia followed by release of endotoxins occurs. There is release of inflammatory mediators like TNF, IL-1, IL-6, and IL-10 leading to hemodynamic insufficiency [4] . The commonest cause of cholangitis is biliary obstruction. Choledocholithiasis, strictures and malignancy are the common causes of obstruction. However there is wide spectrum of causes for biliary obstruction. (Table 1) Ascending cholangitis can occur due to migration of bacteria from the duodenum into the common bile duct [5] . Rarely do bacteria translocate from the portal vein into the bile duct. Other rare causes of cholangitis are primary biliary cholangitis, primary sclerosing cholangitis, Ig G4 related autoimmune cholangitis, and recurrent pyogenic cholangitis or oriental cholangiohepatitis [6] .