Immediate investigations in cholangitis include: (1)
- blood cultures
- blood tests
- FBC
- urea and electrolytes
- LFTs - alkaline phosphatase, GGT, AST, ALT, and bilirubin
- G+S
- ultrasound imaging of biliary tree. This is the first-line imaging study of choice.
These can be followed by:
- CT
- standard CT, and the more recently available helical (spiral) CT, can further assess the anatomy of underlying lesions and help clarify the site of obstruction, and may be needed to plan treatment
- ERCP
- the definitive investigation in acute cholangitis to elucidate the cause and site of obstruction
- may be therapeutic if the stone can be removed through a sphincterotomy or an obstruction stented
- PTC
- however, a drain must be left in the bile ducts
The most sensitive modalities for detecting common bile duct stones are magnetic resonance cholangiopancreatography (MRCP). MRCP is a non-invasive imaging study that can detect the cause and the level of biliary obstruction, including choledocholithiasis, strictures, and biliary dilatations (2)
N.B. direct cholangiography is dangerous because it may worsen the sepsis.
Reference:
- Mohammad Alizadeh AH. Cholangitis: Diagnosis, Treatment and Prognosis. J Clin Transl Hepatol. 2017 Dec 28;5(4):404-413.
- Miura F et al. Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007;14(1):27-34.