cholangitis

Cholangitis: description

Cholangitis (bile duct inflammation) causes inflammation of the biliary tract connecting the gallbladder to the small intestine. The bile is formed by the liver cells and thickened and stored in the gallbladder. When food is taken, the bile is released via the bile ducts increasingly to the duodenum (duodenum). The bile acids contained in it are needed in the intestine to split and digest the fats absorbed through the diet. In addition, toxic substances are released from the body via the liver and biliary tract into the intestine and excreted in 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 result in purulent inflammation of the biliary tract (cholangitis). Since overweight women over the age of 40 years are at an increased risk for gallstones, they are two times more likely to develop cholangitis than men.

Primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a special type of bile duct inflammation and is one of the autoimmune diseases. It is a chronic progressive inflammation of the bile ducts inside and outside the liver. The disease is closely related to other autoimmune diseases such as the chronic inflammatory bowel disease ulcerative colitis. The PSC leads in the further course to scarring (sclerosis) of the biliary tract to the gall bladder (cholestasis). At a later stage, sufferers often develop liver cirrhosis, which can only be treated with a liver transplant.

Cholangitis: symptoms

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

Acute (bacterial) cholangitis: symptoms

The typical cholangitis symptoms here are severe pain in the right upper abdomen, which are described as consistent and constant. Those affected often also suffer from fever to over 40 degrees Celsius and a pronounced malaise. Cholangitis also causes yellowing (jaundice) of the skin 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 eliminated via the bile, passes into the blood and deposits in the skin and mucous membranes. The yellowing of the skin (icterus) can be accompanied by a strong itching.

Primary sclerosing cholangitis: symptoms

Patients with primary sclerosing cholangitis also suffer from a yellowing of the skin, which in most cases is accompanied by an excruciating itching. Patients also have chronic inflammatory bowel disease (ulcerative colitis) in 80 percent of cases. The risk of bacterial inflammation of the bile ducts is increased in the PSC. Such bacterial cholangitis can occur in spurts. 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 are due to very different causes:

Acute cholangitis caused by intestinal bacteria

Acute cholangitis is often caused by intestinal bacteria, which migrate from the small intestine via the common bile duct (ductus choledochus) into the gallbladder and bile duct system. The common bile duct, together with the pancreatic duct (ductus pancreaticus), leads to the duodenal papilla in the duodenum (duodenum). The opening of the common duct is regulated by a sphincter. Although the sphincter usually prevents intestinal bacteria from rising into the liver, it can still happen and, as a result, lead to cholangitis.

Acute cholangitis caused by gallstones (cholelithiasis)

Gallstones are usually caused by a high cholesterol content in the bile. Overweight women over the age of 40 are at particular risk and often have gallstones. The gallstones can migrate from the gallbladder into the biliary system and block the biliary tract, causing the bile to back up – sometimes to the liver. The stagnant secretion can not drain properly and bacteria can multiply more easily. Similar to stagnant water in nature, a lack of runoff makes it more likely to create an imbalance between bacteria. It then leads to irritation of the bile duct mucosa and a purulent inflammation (cholangitis) spreads faster.

Primary sclerosing cholangitis (PSC): autoimmune disease

Primary sclerosing cholangitis (PSC) is a special form of cholangitis underlying 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 backflow of bile with inflammatory thrusts.

Often the PSC also occurs as part of a chronic inflammatory bowel disease (ulcerative colitis). If, in addition to the symptoms typical of cholangitis, there are also slimy bloody diarrhea, it is always necessary to think of a PSC.

Cholangitis: examinations and diagnosis

The right contact person for suspected cholangitis is a specialist in internal medicine or gastroenterology. The doctor will inquire about your current symptoms in a first interview and ask you to describe the course of the symptoms and any previous medical conditions (anamnesis). The doctor will ask you the following questions:

• Do you suffer from abdominal pain?
• Are the abdominal pain convulsive or constantly persistent?
• Do you have fever?
• Do you have a history of inflammatory bowel disease (ulcerative colitis)?
• Have you ever had gallstones?

Afterwards, the doctor will examine you physically, first looking at your skin more closely. A possible yellowing of the skin or so-called liver skin signs indicate a liver damage. Liver skin signs are typical skin changes that occur in chronic liver diseases such as star-shaped dilation of skin vessels (Spider naevi), redness of the palms (Palmaerythem) and reddish, smooth lips (lacquered lips).

The doctor will then use your stethoscope to listen to your stomach to check the bowel sounds and bowel air and stool content. Then the doctor will feel your belly off. The doctor often presses under the right costal arch and asks the patient to take a deep breath. If the pain intensifies and the inhalation is stopped, the suspicion of an inflamed gallbladder (cholecystitis) is confirmed.

Since the physical examination can only conditionally detect cholangitis, further investigations generally follow:

blood test

The doctor can detect signs of inflammation in the presence of cholangitis using the blood test. Elevated levels of C-reactive protein (CRP) and white blood cells (leukocytes) indicate bacterial inflammation. These inflammatory parameters in the blood are not specific for cholangitis, but can also occur in the context of other inflammatory reactions of the body.

Ultrasound (sonography)

The ultrasound examination of the abdomen (abdominal ultrasound) can already give first indications of the cause of cholangitis. Extended bile ducts may indicate a bile blockage. If gallstones are in the bile duct system, they usually form in the gallbladder and can best be visualized there.

Endoscopic retrograde cholangiopancreatography (ERCP)

If cholangitis or gallstones are suspected to prevent bile outflow, endoscopic retrograde cholangiopancreatography (ERCP) is considered a safe diagnostic tool. The ERCP allows the visualization of the bile ducts from the inside. A thin tube is advanced over the esophagus and stomach into the duodenum, via which X-ray contrast medium is injected into the common duct of bile and pancreas. Subsequently, the bile duct system is transilluminated with the help of an x-ray machine. If gallstones can be detected, they can be removed directly in the same session by the ERCP (stone extraction by papillotomy).

Cholangitis: treatment

The therapy of 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 the patient high-dose antibiotics. Particularly frequently, the active ingredient group of fluoroquinolones is used. In some cases, a combination of two different antibiotic drug classes is also used to cover a broader spectrum of bacteria (broad spectrum antibiotic).

Cholangitis patients should not eat for at least 24 hours to prevent digestion and bile flow. In addition, patients will receive analgesics (such as metamizole) and antipyretic drugs (such as acetaminophen and ibuprofen). As a rule, the pain then subsides after a few days. Patients should also be careful to consume enough fluid.

Gallstone removal

If cholangitis is due to blockage of the bile ducts caused by gallstones, they must be removed immediately. Endoscopic retrograde cholangiopancreatography (ERCP) can accurately assess bile ducts and remove gallstones. If the removal of the gallstones is not accompanied by an improvement in the symptoms, a so-called stent (tube) can be inserted into the bile duct. The tube keeps the bile duct open, improving the flow of bile into the small intestine.

Gallstones form mainly in the gallbladder and can migrate from there into the bile duct system. After an acute inflammatory thrust, the gallbladder is usually surgically removed (cholecystectomy).

Primary sclerosing cholangitis

The primary sclerosing cholangitis is an autoimmune disease and so far can not be treated causally. Patients with jaundice (jaundice) often suffer from severe itching. The medicinal excretion of bile acids is therapeutic in the foreground. The drug ursodeoxycholic acid helps to dissolve the cholesterol-containing gallstones. In cases of acute inflammatory attacks, antibiotics are also used in PSC. In the course of PSC, scarring of the entire liver tissue (liver cirrhosis) may develop. The last treatment option (ultima ratio) then represents a liver transplant.

Cholangitis: disease course and prognosis

If the cholangitis heals and any gallstones are removed, the prognosis of bile duct inflammation is very good. In most patients, it then remains in a single disease. New relapses (recurrences) can be found in the PSC, but are otherwise rare.

The acute bacterial cholangitis should always be treated immediately antibiotic, so that the bacteria do not spread through the bloodstream throughout the body and lead to blood poisoning (cholangiosepsis). In the advanced stage, the bile duct inflammation can also spread to the remaining liver tissue and cause purulent abscesses.

The longer the cholangitis, the higher the risk of narrowing (strictures) and scarring of the biliary tract. Gallbladder constrictions prevent bile outflow and increase the risk of backlogging. The PSC is also associated with an increased risk of cirrhosis and bile duct cancer (cholangiocellular carcinoma).

The life expectancy of PSC patients is reduced while the acute ones cholangitis is not associated with a limitation of life expectancy.