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Acute Cholecystitis
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|Chronic Peritonitis
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|Ectopic Pregnancy
|Acute Cholangitis
|Acute Abdominal Pain/Peritonitis
|Assessing Abdominal Pain
|Penetrating Abdominal Trauma
|Acute Pancreatitis
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Patients have fever, jaundice, and right upper quadrant pain (Charcot's triad). This is a serious potentially life threatening condition
About
- Cholangitis is a serious life-threatening condition of the
hepatobiliary system
- Bacterial Infection of the Biliary tree
- Cholangitis is an inflammation of the bile duct system.
- Look for a stone in the CBD or some physical cause
Aetiology
- Associated with gallstones in the CBD or impaired biliary flow
- Stasis allows infection in biliary tree
Microbiology
- Escherichia coli, Klebsiella spp., Pseudomonal species, Enterobacter spp.
- Acinetobacter spp. of Gram-negative bacteria, enterococcus, streptococcus
- Staphylococcus Gram positive bacteria
Types
- Primary sclerosing (PSC)
- Secondary (acute) cholangitis (subject here)
- IgG4-associated cholangitis (IAC)
Causes
- Gallstones
- Benign and malignant strictures
- Primary sclerosing cholangitis
- Chronic pancreatitis
- HIV related cholangiopathy
Clinical
- "Charcot's triad" - Jaundice, RUQ pain, Fever/Rigors
- "Reynolds' pentad" - Jaundice, RUQ pain, Fever/Rigors + Confusion and shock
- Biliary obstruction - dark urine and pale stool
Diagnostic Criteria
- Clinical features
- 1. Previous biliary disorder
- 2. Fever and/or chills
- 3. Jaundice
- 4. Abdominal pain
- Laboratory
features
- 5. Presence of inflammation indicators
(elevated leukocyte count, positivity for
C-reactive protein)
- 6. Elevated liver enzymes
- Imaging
findings
- 7. Biliary dilatation, other abnormalities
suggesting hepatobiliary disorder
- Suspected
diagnosis
Two or more items of clinical features
- Definite
diagnosis
Either Charcot's triad (2+3+4) or two
items in the clinical features along with
both items in the laboratory and imaging
findings
Investigations
- FBC: Raised WCC and CRP
- LFT'S usually Raised ALP and Raised GGT Raised Bilirubin
- USS to look for stones and CBD dilatation
- Abdominal CT can be useful
- ERCP allows imaging and identification and release of stone by sphincterotomy possibly. It is the gold standard for diagnosis of cholangitis
Complications
- Sepsis, hypotension, multi-organ failure, and mental status changes.
- Empyema of the gallbladder is a suppurative infection of the gallbladder,
in which the gallbladder fills with infected fluid, eventually leading to pus
Management
- IV fluids and resuscitation and basic ABC's. Start IV Antibiotics but alone these do not provide sufficient treatment in the majority of patients. Drainage of the biliary tree is the most critical step in management.
- IV antibiotics - various regimens e.g. Cephalosporin/Metronidazole or Amoxicillin and Gentamicin
- ERCP usually with a sphincterotomy to allow a stone to pass and provide biliary drainage. Important to correct any coagulopathy before a sphincterotomy.
- If there is a malignant lesion or stricture a stent can be placed by ERCP or sphincterotomy performed
- Consider cholecystectomy at 6-12 weeks for gallbladder stones and is commonly done laparoscopically nowadays
References