Cholangitis

CHOLANGITIS (syn. angiocholitis), an inflammatory disease of the bile ducts both inside and outside the liver. Most often, cholangitis is combined with inflammatory processes occurring in the gallbladder. This particularly applies to the so-called extrahepatic cholangitis, which mainly affects the large bile ducts (d. choledochus, d. cysticus and d. hepaticus). In these cases, we are dealing with angiocholecystitis with predominant involvement of the gallbladder in some patients or of the bile ducts in others. The second form more often involves both large and small bile ducts inside the liver, creating an anat.-clin. picture of cholangitis in the proper sense.-According to the nature of the lesion, catarrhal and suppurative cholangitis are distinguished. By duration of course, catarrhal cholangitis can be acute and chronic. Suppurative cholangitis, however, almost always has a severe course and very rarely transitions to a chronic form. The clinical picture of catarrhal forms of cholangitis is outlined very vaguely and indistinctly. The widespread opinion is that with cholangitis, the mucous membrane of the bile ducts swells and thus conditions are created for the development of mechanical ('catarrhal') jaundice, enlargement of the liver, etc. However, at present time, these forms of jaundice are correctly interpreted as parenchymal liver lesions and cannot be considered a consequence, let alone the main symptom of cholangitis. Among the most frequent subjective symptoms in cholangitis, only dull pains or a feeling of heaviness in the epigastric region should be emphasized. Along with this, a moderate enlargement of the liver is observed objectively with a smooth surface and normal consistency. The fever caused by acute catarrhal cholangitis is usually slight and has a remittent character. In most cases, the elevation of temperature from cholangitis is masked by the simultaneous presence of a general disease (e.g. typhoid fever) or of gallbladder involvement (acute cholecystitis). The most reliable objective sign of catarrhal cholangitis is therefore the presence of pathological elements in the duodenal contents, especially in 'bile A', in the form of an admixture of mucus, a significant number of leukocytes, and sometimes also erythrocytes and squamous epithelium. Simultaneously in the blood, a moderate neutrophilic leukocytosis is detected.-In chronic catarrhal cholangitis, the clinical symptomatology is even more meager and atypical. Subjective complaints are most often absent. The liver is persistently enlarged, and in the contents of the duodenum, the mentioned pathological admixtures sometimes appear, which usually correspond to irregular elevations of temperature. Chronically occurring cholangitis extremely exhausts patients and often leads to secondary functional disturbances in the liver with auto-intoxication and sharp weight loss of the patient. The third group of cholangitis, caused by suppurative inflammation of the bile ducts, especially small ones, is undoubtedly of greatest practical importance. The disease is similar in its manifestation to septicopyemia, as it proceeds with high fever, chills, more or less jaundice, and a painful liver. The suppurative process often extends from the bile ducts to the surrounding liver tissue, as a result of which multiple small abscesses of the liver develop. To the severe general picture of suppurative cholangitis there also corresponds a high neutrophilic leukocytosis with a sharp shift of the formula to the left, a high erythrocyte sedimentation rate, as well as a rapid, developing before one's eyes anemia of the patient. In individual, though rare, cases, septic cholangitis has a prolonged character with alternating exacerbations and subsidence in the course of the process. Such forms gave rise to speak of a special latent, slowly progressing septic cholangitis (cholangitis lenta) (Loewenhardt, Vovsi). From the blood and bile of such patients, it is sometimes possible to isolate the same microbe-pathogen of the disease (Streptococcus viridans, staphylococcus). Etiology and pathogenesis. True cholangitis is always caused by infection. Indeed, the pathogen of the disease can obviously be very diverse. In acute cases, cholangitis most often arises on the basis of infection of the bile ducts by a group of intestinal bacilli, Ebert's bacillus, cholera vibrio, and even pneumococcus. Occasionally typical typhoid cholangitis are observed, and changes in the intestine may be weakly expressed or even absent (cholangotyphus). In chronic patients, one of the causes of cholangitis can be, along with the usual infectious agents, also the penetration of protozoa and parasites (giardia, worms) into the bile ducts. In cases of suppurative (septic) cholangitis, the etiological factor is the introduction, most often into the small bile ducts, of strepto- and staphylococcal infection. At the same time, it should be noted that in such, essentially septic, patients, cholangitis is as a rule the only visible localization. The mechanism of development of the cholangitic process remains controversial to this day. The view, still recently widely accepted, of cholangitis as an ascending infection from the intestine now raises many objections. Many facts and research have accumulated, indicating the possibility of infection of the bile ducts by hematogenous and lymphogenous pathways-through the branches of the hepatic artery, portal vein and lymphatic vessels, since many bacteria, as is known, are excreted from the blood along with bile into the intestine. Course and outcome. Catarrhal cholangitis accompanying acute infectious diseases proceeds relatively easily and often ends favorably. The chronic forms of this disease, as mentioned, give repeated exacerbations with fever, the appearance of inflammatory changes in the bile, leukocytosis, etc. Accordingly, in the tissues surrounding the bile ducts inside the liver, periangiocholitis develops, the degree of which in individual cases can be very significant. That is why in chronic cholangitis, secondary cirrhotic changes in the liver are often observed: proliferation of connective tissue and often death of liver parenchyma. Severe forms of such cholangitic cirrhosis are also accompanied by a decrease in the functional capacity of the liver. Suppurative cholangitis as a rule lead to the formation of periangiocholitis, as a result of which in the liver along the course of the bile ducts, small multiple abscesses develop. Sometimes larger abscesses of the liver of hematogenous-metastatic origin can also be observed. The outcome of suppurative cholangitis, especially complicated by abscesses in the liver, is absolutely unfavorable. Treatment of cholangitis presents considerable difficulties due to the inaccessibility of the bile ducts for therapeutic intervention. The main task is the emptying (resp. drainage) of the bile ducts from infected contents, as well as, if possible, the disinfection of the bile itself. The best results in catarrhal forms of cholangitis are given by systematic washings through a duodenal tube with a warm solution of magnesium sulfate (50 cm³-30%-solution or 100 cm³-15%-solution). At the same time, atropine and papaverine are used to relax the sphincters of the bile-excretory system. However, increased bile outflow does not give the desired results in lesions of the small bile passages in the liver, which is why in these patients, in addition, systematic injections of urotropine into the vein (40%-solution 5 cm³) are especially indicated. In chronically occurring cases, to prevent functional insufficiency of the liver, it is necessary to prescribe to patients a carbohydrate-rich diet. Suppurative cholangitis hardly respond to conservative treatment. Surgical intervention in the form of permanent drainage of the bile ducts gives an effect also only in the early phase of the disease, before the development of abscesses in the liver itself.