Acute Cholangitis

Related Subjects: Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain/Peritonitis |Assessing Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

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

• Cholangitis: Diagnosis, Treatment and Prognosis