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Cholangitis

Cholangitis refers to the acute inflammation of the biliary tree and the subsequent obstruction of bile flow. Pathologists recognize two forms: pyogenic cholangitis, caused by a bacterial infection, and sclerosing cholangitis, which is thought to be an autoimmune disorder. Cholangitis is usually precipitated by an obstruction of the common bile duct, which develops a secondary infection. Stones are the common causes of bile duct obstruction, but other factors could include strictures, stenosis, tumors, parasites or endoscopic procedures of the common bile duct. Such obstructions allows bile to stagnate in the biliary tree, enhancing bacterial colonization. The increased biliary pressure and backflow into the liver allows bacteria to spread into the bile canaliculi, veins and lymphatics, spreading into the blood. (Berkow 1992; Santen 2003)

The most important clinical signs of cholangitis include the Charcot triad, including:

  • right upper quadrant (RUQ) pain
  • fever
  • jaundice

The Charcot triad represents the most common symptoms observed in cholangitis, but can vary from mild to severe. In some patients the pain may be so debilitating so as to make for difficulty is pin-pointing the location, and thus in any severe abdominal pain the case history should be reviewed for previous symptoms of gallbladder pain, cholelithiasis or related disorders. (Berkow 1992; Santen 2003)

Common bacterial components of obstructed bile include Escherichia coli (39%), Klebsiella (54%), Enterobacter (34%) species, enterococci (34%), and group D streptococci, with more than one organism sometimes being involved. Cholangitis is relatively uncommon in North America but very common in South East Asia, most often occurring with diseases or medical procedures that cause biliary obstruction. Primary infectious causes include intestinal parasites (e.g. Ascaris lumbricoides) and yeast (Candida spp.), which can obstruct bile flow and promote secondary bacterial infection. The mortality of cholangitis is up to 40%, more common in elderly patients and/or those suffering from renal failure, liver disease, inflammatory bowel disease and tumors. (Berkow 1992; Santen 2003)

Unlike pyogenic (bacterial) cholangitis, primary sclerosing cholangitis (PSC) is a chronic liver disease characterized by inflammation, destruction and fibrosis of the bile ducts, eventually leading to cirrhosis of the liver. Very often PSC is complicated by recurrent episodes of bacterial cholangitis, making it difficult to distinguish between the two, suggesting varied and synergistic etiological factors. Patients with PSC have an increased risk of cancer of the bile duct. (Berkow 1992; Santen 2003)

While some have postulated infectious agents, toxins or chronic infection as a cause of PSC, most researchers suspect that it is an autoimmune disease since about 75% of cases are concurrent with established AI diseases such as ulcerative colitis. Important laboratory investigations are elevated serum alkaline phosphatase and gamma-glutamyltranspeptidase, with slight elevations in serum aminotransferase. Other important markers may include serum gamma-globulin and serum IgM antibodies directed against perinuclear antigen in neutrophil cytoplasm (ANCA), anti-smooth muscle (actin), and antinuclear antibodies). (Lee and Kaplan 1995)

Symptoms and signs of PSC include pruritus, jaundice, fatigue, fever, weight loss and signs of advanced liver disease. Some patients present with the symptoms of pyogenic cholangitis, including fever, chills and RUQ pain. PSC is a progressive disease, often complicated by recurrent bouts of bacterial cholangitis, and in most cases leads to cirrhosis and liver failure within 10 years of diagnosis. (Berkow 1992; Santen 2003)

Medical treatment

The medical treatment of pyogenic cholangitis consists of an intravenous combination broad-spectrum antibiotics, including penicillin (e.g. piperacillin, ampicillin, penicillin) and metronidazole; penicillin and metronidazole plus an aminoglycoside (e.g. gentamicin, tobramycin); an aminoglycoside and third-generation cephalosporin; piperacillin and tazobactam; mezlocillin; imipenem; meropenem; ticarcillin and clavulanate; or ampicillin and sulbactam. In very ill patients the infected regions of the biliary tree are drained percutaneously or endoscopically. (Santen 2003)

In contrast, the medical treatment of primary sclerosing cholangitis is limited to purely symptomatic measures. The bile acid ursodeoxycholic acid is used to improve disturbed laboratory parameters, and cholestyramine and opioid antagonists are given to control itching. Deficiencies in fat-soluble vitamins and essential fatty acids are very common, and should be treated with supplementation. Aggressive antibiotic therapy is used to treat episodes of bacterial cholangitis. (Berkow 1992; Santen 2003)

Holistic treatment

Acute bacterial cholangitis is a life-threatening condition and patients presenting with Charcot’s triad should be immediately referred to emergency care. Thus the kind of patient with cholangitis that is likely to be seen by a herbalist will be those in which the symptoms are relatively mild, or in the case of PSC, chronic. Given this caveat, a number of remedies and interventions are considered to be helpful in cholangitis.

1. Dietary modifications. For acute scenarios refer to the dietary strategies mentioned under “bilious dyspepsia,” with an observance of the rule “light, little and liquid” with a preference to fresh vegetable juices and vegetable broths to avoid stimulating too much in the way of digestive activity. Given that PSC is in all likelihood an autoimmune disorder the Paleolithic diet discussed in The Fire Within: Digestive Function and Botanical Medicine should be resorted to control or halt the progression of the disease. For cholangitis associated with gallstones refer to the section under cholelithiasis.

2. Cholagogues and choleretics. In his text Herbal Repertory in Clinical Practice (1990) Michael Moore differentiates among the most potent cholagogues in the Western materia medica, used in small drop doses.

  • For acute pain: Culver’s root (Leptandra virginica)
  • Pale stools, cloudy or dark urine, pain in right hypochondrium to shoulder: Celandine Poppy (Chelidonium majus)
  • Pale stools, cloudy or dark urine, pain in right hypochondrium to navel: Fringe Tree (Chionanthus virginicus)
  • Sharp cutting pains, increased by motion: Fringe Tree (Chionanthus virginicus)

3. Antispasmodics. To relieve pain, e.g. Wild Yam (Dioscorea vilosa), Kava (Piper methysticum), Cramp Bark (Viburnum opulus), Caraway (Carum carvi), Fennel (Foeniculum vulgare), Rocky Mountain Oregano (Brickellia veronicifolia), Bitter Ash (Picraena excelsa), Jamaican Dogwood (Piscidia erythrina), Valerian (Valeriana officinalis), Marijuana (Cannabis sativa), Shatavari (Asparagus racemosa), Yan Hu Suo (Corydalis cava), Bai Shao (Paeonia lactiflora); tropane-alkaloid containing plants, e.g. Belladonna (Belladonna atropa), Henbane (Hyocyamus niger)

4. Antimicrobials, to relieve heat (Pitta). Including Purple Coneflower (Echinacea angustifolia), Garlic (Allium sativum); avoid using with bitter antimicrobials e.g. Goldenseal (Hydrastis canadensis), Barberry (Berberis vulgaris), Huang Lian (Coptis chinense), Huang Qin (Scutellaria baicalensis), Nimba (Azadirachta indica)

5. Chinese formulae: from a Chinese perspective cholangitis is a damp heat condition. The following formulae as base formulae to which are made slight modifications depending upon the signs and symptoms.

  • Da Chai Hu Tang (Major Buplerum combination), alternating fever and chills, nausea and vomiting, epigastric pain and distension, with burning diarrhea or constipation, a bitter taste in the mouth, a yellow tongue coating, and a forceful pulse; Rx: decoction (1:4), one cup thrice daily (Bensky and Barolet 1990, 139)
  • Xiao Chai Hu Tang (Minor Buplerum combination), for alternating fever with chills, a dry throat, a sour taste in the mouth, dizziness, irritability, sensation of fullness, gastric reflux, nausea, anorexia, a thin white coating on tongue, a wiry pulse; Rx: decoction (1:4), one cup thrice daily (Bensky and Barolet 1990, 136)

The following are useful Chinese patent remedies:

  • Li Dan Pian (Benefit Gall Bladder pills), resolves damp-heat and toxic heat in the Liver and Gall Bladder; Rx: 6 tablets thrice daily (Fratkin 1986, 96)
  • infection; Rx: 4-10 tabs twice daily (Fratkin 1986, 96)
  • Li Dan Pai Shi Pian (Benefit Gall Bladder Discharge Stone tablet), resolves damp-heat and toxic heat in the Liver and Gall Bladder, useful in Ascaris

Cholangitis and PSC are difficult conditions to treat, and where possible, herbal treatment should be undertaken in conjunction with the patient’s medical doctor. Where gall stones can be seen to be the underlying cause of cholangitis, therapy can be undertaken to dissolve and eliminate the stones, only as long as the stones aren’t too large to be passed, and thus must first be assessed by radiological or ultrasonic methods.

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