Liver & intrahepatic bile ducts
Biliary tract disease
Ascending cholangitis

Editor-in-Chief: Debra Zynger, M.D.
Raul S. Gonzalez, M.D.

Topic Completed: 5 September 2019

Minor changes: 5 September 2019

Copyright: 2002-2019,, Inc.

PubMed Search: Ascending cholangitis[mh] liver

Raul S. Gonzalez, M.D.
Page views in 2019: 1,642
Page views in 2020 to date: 1,461
Cite this page: Gonzalez RS. Ascending cholangitis. website. Accessed September 21st, 2020.
Definition / general
Essential features
  • Highly morbid infection of large bile ducts
  • Histologic correlate is neutrophils within epithelium and lumen of interlobular bile ducts
  • Also called acute cholangitis, suppurative cholangitis
ICD coding
  • ICD-10: K83.09 - other cholangitis
Clinical features
  • Endoscopic retrograde cholangiopancreatography (ERCP) obtained bile can be cultured to guide antibiotic therapy (Dig Dis 2019;37:155)
    • Blood culture may be less successful
Case reports
  • Biliary drainage and antibiotic therapy
Microscopic (histologic) description
  • Neutrophils within lumens of interlobular bile ducts and also infiltrating duct (not ductule) epithelium (Lefkowitch: Scheuer's Liver Biopsy Interpretation, 9th Edition, 2015)
    • Note: neutrophils sprinkled throughout ductular reaction is a typical component of ductular reaction and should NOT be considered evidence of infection or of ascending cholangitis
  • Larger ducts often unaffected
  • Findings of other concomitant biliary processes (e.g. large duct obstruction) may also be present
Microscopic (histologic) images

Contributed by Raul S. Gonzalez, M.D.

Neutrophilic infiltrate

Sample pathology report
  • Liver, biopsy:
    • Hepatic parenchyma with cholestasis and neutrophils involving bile duct lumens and epithelium (see comment)
    • Comment: The findings are concerning for acute (ascending) cholangitis in the proper clinical context.
Differential diagnosis
  • Acute cellular rejection of liver transplant:
    • Neutrophils within duct lumen may rarely be present
    • Clinical correlation necessary, as duct complications / infection can also occur in the posttransplant setting
  • Sepsis:
    • May occur alongside ascending cholangitis
    • Nonspecific cholestasis and acute / chronic inflammation, though ductular cholestasis is highly suggestive of sepsis
Board review style question #1
Neutrophils filling the lumens of native interlobular bile ducts are most suggestive of which diagnosis?

  1. Ascending cholangitis
  2. Cholangiocarcinoma
  3. Primary biliary cholangitis
  4. Primary sclerosing cholangitis
  5. Recurrent pyogenic cholangitis
Board review answer #1
A. Ascending cholangitis

Reference: Ascending cholangitis

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Board review style question #2
A patient presents with fever, jaundice and abdominal pain. Liver enzymes are elevated and a liver biopsy is performed. You see the following finding.

Based on this, which of the following steps may be included in the patient's therapy?

  1. Antibiotics
  2. Bile duct excision
  3. Platinum based chemotherapy
  4. Steroids
  5. Ursodeoxycholic acid
Board review answer #2
A. AntibioticsĀ (this is ascending cholangitis)

Reference: Ascending cholangitis

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