Liver and intrahepatic bile ducts - nontumor
Biliary tract disease
Recurrent pyogenic cholangitis

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

Topic Completed: 17 December 2019

Minor changes: 30 January 2020

Copyright: 2002-2019, PathologyOutlines.com, Inc.

PubMed Search: Recurrent pyogenic cholangitis [title]

Raul S. Gonzalez, M.D.
Page views in 2019: 304
Page views in 2020 to date: 167
Cite this page: Gonzalez RS. Recurrent pyogenic cholangitis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/liverorientalcholangiohepatitis.html. Accessed May 24th, 2020.
Definition / general
  • Recurrent attacks of obstructive cholangitis due to Escherichia coli infection in the setting of liver fluke infection or hepatolithiasis
Essential features
  • Recurrent bile duct injury due to flukes, hepatoliths or bacterial infection
  • Treatment often requires surgery
  • Patients are at increased risk for cholangiocarcinoma
Terminology
ICD coding
  • ICD-10: K83.09 - other cholangitis
Epidemiology
Etiology
  • Patients often have liver flukes (e.g. Clonorchis sinensis) or hepatolithiasis as the initial inciting factor (J Emerg Med 2012;43:e107)
  • E. coli, found in the bile of most patients during acute attacks, appears to be the second inciting factor
Clinical features
  • Usually occurs in young adults of either sex; more common in rural areas (Abdom Radiol (NY) 2017;42:46)
  • Symptoms: acute or recurrent bouts of suppurative cholangitis accompanied by abdominal pain, fever and jaundice (Semin Liver Dis 2011;31:33)
  • Patients are at increased risk for developing cholangiocarcinoma
Radiology description
  • Dilation of extrahepatic bile ducts with relatively mild / no dilation of intrahepatic ducts, localized dilatation of the lobar or segmental bile ducts, increased periportal echogenicity, segmental hepatic atrophy, gallstones (Clin Res Hepatol Gastroenterol 2012;36:515, Abdom Radiol (NY) 2017;42:46)
  • Peripheral ducts may taper abruptly (Abdom Radiol (NY) 2017;42:2964)
  • Localized intrahepatic segmental ductal stenosis may be present, especially in the lateral segment of the left lobe or posterior segment of the right hepatic lobe
Radiology images

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Cholangiogram
 with stones

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CT with stones

Prognostic factors
Case reports
Treatment
Clinical images

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Intrahepatic stone

Gross images

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Duct dilatation and stones

Microscopic (histologic) description
  • Dilation and fibrosis of bile ducts with acute or chronic inflammation (Adv Anat Pathol 2011;18:318)
  • Other findings include hepatic / intraductal abscesses and secondary sclerosing cholangitis
  • Liver flukes or bile duct stones may be seen
Microscopic (histologic) images

Contributed by Raul S. Gonzalez, M.D.
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Hepatolithiasis

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Periductal fibrosis

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Duct inflammation

Sample pathology report
  • Liver, right lobe, partial hepatectomy:
    • Bile ducts with acute and chronic inflammation, fibrosis and hepatolithiasis (see comment)
    • Background liver parenchyma with reactive change
    • Comment: The findings are compatible with the patient’s reported history of recurrent pyogenic cholangitis. The examined sections are negative for dysplasia or malignancy.
Differential diagnosis
Board review style question #1
    A young Asian patient presents with recurrent abdominal pain. Workup indicates hepatolithiasis with obstructive cholangitis. Which bacteria is most likely contributing to his symptoms?

  1. Escherichia coli
  2. Mycobacterium tuberculosis
  3. Pseudomonas aeruginosa
  4. Shigella sonnei
  5. Staphylococcus aureus
Board review answer #1
A. Escherichia coli

Reference: Recurrent pyogenic cholangitis

Comment Here
Board review style question #2
    A 50 year old Asian woman is found to have a liver mass. Biopsy is consistent with cholangiocarcinoma. She endorses a history of recurrent abdominal pain and fevers. What is the most likely underlying diagnoses?

  1. Benign recurrent intrahepatic cholestasis
  2. Crohn’s disease
  3. Longstanding drug induced liver injury
  4. Primary biliary cholangitis
  5. Recurrent pyogenic cholangitis
Board review answer #2
E. Recurrent pyogenic cholangitis

Reference: Recurrent pyogenic cholangitis

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