Signs and symptoms of ascending cholangitis (also known as acute cholangitis) develop due to the obstruction of the biliary tree (by gallstones or choledocholithiasis, tumors or benign strictures are known as pathogenic mechanisms) and secondary bacterial colonization of the bile ducts from the gastrointestinal tract or the portal venous system [1] [2]. As a result, bacteria are able to reproduce and proliferate in this tight environment (as bile is not capable of flushing them back into the duodenum along its pathway), causing an intense inflammatory reaction and symptoms of abdominal pain, jaundice and fever, known as the Charcot's triad [3] [4] [5]. Although this clinical entity was described more than 100 years ago, most recent guidelines have proposed the exclusion of abdominal pain from constitutive features of acute cholangitis, because of a rather low report rate by patients [5] [6]. Indeed, the presence of a complete Charcot's triad ranges from 15.4–72.0%, which is why fever and jaundice remain the most important features [4]. Ascending cholangitis is life-threatening, with mortality rates being 2.5-3.5%, but in the absence of an early diagnosis, dissemination of bacteria in the systemic circulation and sepsis can occur, in which case mortality rates rise to 84-100% without immediate initiation of directed therapy [3] [5] [7]. In fact, septic encephalopathy is seen in up to 9% of cholangitis patients and is manifested as loss of consciousness and shock in most severe cases [5] [7]. Furthermore, some authors add hypotension and altered mental status to the Charcot triad's to form the Reynold's pentad, another diagnostic tool used to identify patients with ascending cholangitis [3] [8].

Acute deterioration of patients that present with jaundice and fever (as well as abdominal pain) must raise clinical suspicion of an inflammatory process in the biliary tree, especially if loss of consciousness or an altered mental state is also present [3]. After obtaining a detailed patient history (if patients are unconscious, friends or family who bring the patient to the hospital can provide valuable information). Conducting a thorough physical examination and a complete laboratory workup is mandatory. A complete blood count (CBC) will almost always show leukocytosis [5], whereas inflammatory parameters - C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and fibrinogen will all be elevated depending on the duration and severity of the infection. Alkaline phosphatase (ALP), bilirubin, and pancreatic amylase levels may be elevated in severe cases [8]. At the same time, blood cultures should be drawn, and they are likely to be positive in the majority of the cases [5]. Bacterial pathogens that cause ascending cholangitis are principally gram-negative Enterobacteriaceae (Escherichia coli, Enterobacter spp, and Klebsiella spp), while gram-positive microorganisms (eg. Enterococcus sp) and anaerobes (Bacteroides spp, Clostridia, and Fusobacterium spp) are less common [8]. On the other hand, imaging studies must be performed early on, including ultrasonography and computed tomography (CT), which is recommended as a first-line procedure [4]. Multidetector CT (MDCT) has shown even greater specificity and sensitivity and should be performed whenever possible, while magnetic resonance cholangiopancreatography (MRCP) is also mentioned as a reliable method to diagnose the condition [3] [4].

The primary goals of treatment for ascending cholangitis are to relieve the bile duct obstruction and to treat the infection. Antibiotics are administered to combat the bacterial infection. In many cases, an ERCP is performed to remove the obstruction, such as a gallstone, and to drain the bile duct. In severe cases, surgical intervention may be necessary. Supportive care, including fluids and pain management, is also crucial.

With prompt and appropriate treatment, the prognosis for ascending cholangitis is generally good. However, if left untreated, the condition can lead to serious complications, including sepsis (a life-threatening response to infection), liver abscesses, or even death. Early recognition and intervention are key to improving outcomes.

The most common cause of ascending cholangitis is obstruction of the bile duct by gallstones. Other potential causes include strictures (narrowing of the bile duct), tumors, or parasites. The obstruction allows bacteria, typically from the intestine, to ascend into the bile duct, leading to infection.

Ascending cholangitis is more common in adults, particularly those with a history of gallstones. It is less common in children. The incidence of the condition varies globally, with higher rates in regions where gallstones are more prevalent. Risk factors include age, obesity, and certain medical conditions such as cirrhosis or inflammatory bowel disease.

The pathophysiology of ascending cholangitis involves the obstruction of bile flow, which creates a favorable environment for bacterial growth. The stagnant bile becomes infected, and bacteria can ascend from the duodenum (the first part of the small intestine) into the bile duct. The resulting infection and inflammation can spread rapidly, leading to systemic symptoms and complications.

Preventing ascending cholangitis primarily involves managing risk factors for bile duct obstruction. This includes maintaining a healthy weight, managing cholesterol levels, and addressing any underlying conditions that may contribute to gallstone formation. In some cases, prophylactic measures, such as the removal of the gallbladder (cholecystectomy) in patients with recurrent gallstones, may be considered.

Ascending cholangitis is a serious infection of the bile duct system, often caused by obstruction due to gallstones. It presents with fever, jaundice, and abdominal pain, and requires prompt medical intervention. Diagnosis involves clinical evaluation, laboratory tests, and imaging studies, with ERCP playing a key role in both diagnosis and treatment. With timely treatment, the prognosis is generally favorable, but prevention through risk factor management is essential.

If you or someone you know is experiencing symptoms such as fever, jaundice, and abdominal pain, it is important to seek medical attention promptly. Ascending cholangitis is a serious condition that can lead to severe complications if not treated quickly. Understanding the risk factors, such as gallstones, and maintaining a healthy lifestyle can help prevent this condition. Always consult with a healthcare professional for personalized advice and treatment options.

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