Cholangitis: from diagnosis to treatment

The diagnosis of cholangitis should be made in the presence of chronic cholestasis, after ruling out chronic viral hepatitis, medication and with normal hepatic ultrasound. The clinical signs of cholangitis are not specific: asthenia, pruritus. Anti-mitochondrial antibody (AMA) testing is the first key step in diagnosis. When positive, the diagnosis is primary biliary cholangitis (PBC). This is a destructive autoimmune disease of the small bile ducts, mainly affecting women around the age of 50. First-line treatment with ursodesoxycholic acid (AUDC) slows the progression to cirrhosis and its complications. When anti-mitochondrial antibodies are negative, cholangio-MRI is recommended to identify bile ducts strictures, which may suggest the diagnosis of primary sclerosing cholangitis (PSC). This inflammatory disease of the large bile ducts tends to affect men aged around 40, and is very frequently associated with IBD. Treatment of PSC is also based on AUDC. Complications of PSC include angiocholitis, cholangiocarcinoma and cirrhosis, with the risk of decompensation. When associate with IBD, there is also an increased risk of colon cancer, justifying annual imaging surveillance of the bile ducts and also annual surveillance of the colon.