10. ACUTE CHOLANGITIS Flashcards
Definition of Acute Cholangitis
Acute Cholangitis is an ascending bacterial infection in association with partial or complete obstruction of the bile ducts. It was first described by Charcot as a serious and life-threatening illness.
However, it is not recognized that the severity can range from mild to life-threatening.
ETIOPATHOGENESIS
Normally, hepatic bile is sterile and the ducts are also kept sterile by the continuous bile flow in an unobstructed duct and the antibacterial substances in bile also play a role.
That being said, there are 2 factors that are necessary for cholangitis to occur.
- Biliary obstruction
- Bactobilia
Biliary bacterial contamination alone does not lead to clinical cholangitis. The combination of both significant bacterial contamination and biliary obstruction is required for its development.
The MOST COMMON causes of biliary obstruction are:
1. Biliary stones - 85%
2. Obstructing neoplasms - ampullary cancer, pancreatic head cancer, distal cholangiocarcinoma
3. Bile duct strictures/stenosis
Other potential causes of bile duct obstruction would are parasitic infections such as clonorchis sinensis/ascaris lumbricoides/
Infections are usually polymicrobial and it is rare to see only one organism causing the infection
Bacterial like e.coli, enterococcus sp., klebsiella, pseudomonas aeruginosa would be the ones isolated.
In the presence of obstruction, bacteria would gain access in to the biliary tree via ASCENDING ROUTE (Duodenobilious Reflux) or DESCENDING ROUTE (Hematogenous Spread),
ASCENDING ROUTE - duodenal bacteria are able to enter the biliary system in high concentrations when the barrier mechanism is disrupted.
This may occur after invasive procedure such as:
Endoscopic Sphincterotomy
Choledochal surgery
Biliary Stent insertion
However, bacteria can also pass spontaenously through the sphincter of oddi in small numbers
The presence of foreign body such as an obstructing stone can act as a nidus for bacterial infection
DESCENDING ROUTE
On the other hand, bacteria may also reach the biliary tree hematogenously. This happens because Obstruction —> elevated intrabiliary pressure —> increased permeability of the bile ductules to bacteria. This also favors the migration of bacteria from bile —> systemic circulation inc. RISK OF SEPTICEMIA
CLINICAL MANIFESTATIONS
The classic manifestation of Acute Cholangitis is the Charcot’s Triad which is composed of:
- Jaundice
- Abd pain - m/c
- Fever - m/c
Among the three, fever and abdominal pain still remain to be the m/c symtoms with jaundice being less commonly seen
In its more severe form, Acute Suppurative Cholangitis, patient may develop hypotension and alteration in sensorium on top of the Charcot’s triad which is now referred to as the REYNOLD’S PENTAD
In elderly and those patients on glucocorticoids, hypotension may be the only symptom leading to a delay in diagnosis and treatment
In elderly and those patients on glucocorticoids, hypotension may be the only symptom leading to a delay in diagnosis and treatment
On PE, patients may appear confused, agitated and stupurous
Again, the patient is febrile with chills and is jaundiced. On abdominal physical exam, there is right upper quadrant tenderness
Signs of hypotension and sepsis should also be investigated. Because when these are present, these indicate a more severe type of cholangitis and requires urgent biliary drainage.
DIAGNOSIS
In patients with suspected acute cholangitis, several laboratory tests should be requested.
- CBC - would reveal leukocytosis with neutrophil predominance suggesting infection
- Serum Bilirubin would reveal elaveted total and conjugated bilirubin (B2)
- Serum Alkaline Phosphatase would elevated
- Serum Aminotransferases may be high as 2000 IU indicating a pattern of acute hepatocyte necrosis. This reflects microabscess formation in the liver
In patients with suspected acute cholangitis, several laboratory tests should be requested.
- CBC - would reveal leukocytosis with neutrophil predominance suggesting infection
- Serum Bilirubin would reveal elaveted total and conjugated bilirubin (B2)
- Serum Alkaline Phosphatase would elevated
- Serum Aminotransferases may be high as 2000 IU indicating a pattern of acute hepatocyte necrosis. This reflects microabscess formation in the liver
Differential Diagnosis
Biliary leaks Acute diverticulitis Cholecystitis Appendicitis Pancreatitis Liver abscess Infected choledochal cyst Recurrent pyogenic cholangitis Mirizzi syndrome Intestinal perforation Right lower love pneumonia/empyema
Management
Patients with AC should be:
- Placed on NPO
- IV Access secured
- Admitted for evaluation and treatment
The mgt should include
- Treatment and management for SEPSIS
- Biliary drainage
Treatment and management of SEPSIS
These patients may develop septic shock and require frequent monitoring for signs of shock: hypotension, oliguria <0.5 mL/kg/hr, changes in sensorium, metabolic acidosis
If septic shock develops, patients would need additional supportive care to correct physiologic abormalities such as 1. HYPOXEMIA and 2. HYPOTENSION aside from ANTIBIOTICS, to address hypoxemia, supplemental o2 should be suppled to all patients with sepsis & monitored continuously with pulse oximetry
HYPOTENSION - intravascular hypovolemia is typical and severe in sepsis due to generalized increase in capillary permeability
-rapid and large volume infusions of crystalloid solutions 30 mL/kg should be given as boluses and the response should be assessed and boluses are repeated until BP and tissue perfusion are acceptable
ANTIBIOTICS - all patients should be immediately given broad-spectrum empiric IV antibiotics aimed at colonic bacteria which are the common pathogens in acute cholangitis
Choices of Antibiotics
Choice of antibotics: FIRST CHOICE - Monotherapy with B-lactamase inhibitor 1. Ampicillin Sulbactam 3g IV q6 2. Piperacillin Tazobactam 4.5g IV q6 3. Ticarcillin Clavulanate 3.1g IV q4
Combination 3rd gen cephalosporin + Metronidazole
Ceftriaxone 1g IV q 24 + Metronidazole 500 mg IV q8
ALTERNATIVE - combination of Fluoroquinolone + Metronidazole 500 mg IV q8
Ciprofloxacin 300 mg IV q12 or Levofloxacin 500 mg IV q24 + Metronidazole 500 mg IV q8
Meropenem 1g IV q8
Ertapenem 1g IV q24
Regardless of initial drug regimen, therapy should be modified once culture and sensitivity results are available (Culture-guided therapy)
Regardless of initial drug regimen, therapy should be modified once culture and sensitivity results are available (Culture-guided therapy)
When AB treatment is not successful, what to do?
BILIARY DRAINAGE is the mainstay of treatment of Acute Cholangitis
When adequate biliary drainage is accomplished, it can significantly shorten the duration of antibiotic therapy from 7to10 days to 3 days, thus also shortening hospital stay.
Endoscopic Sphincterotomy with stone extraction or stent placement for malignancy and strictures using ERCP is the treatment of choice for drainage. However, occassionally, ERCP may not be technically feasible especially in patients who do not respond to antibiotics and require urgent drainage.
In such cases, biliary drainage can often be achieved by percutaneous transhepatic cholangiography or open surgical decompression (choledotomy) with T-tube placement
Prevention:
Patients who develop acute cholangitis d/t gallstones are at risk for recurrence.
Elective open or laparoscopic surgery is recommended as soon as possible.
If obstruction is due to benign stenosis or strictures, endoscopic therpay or surgical repair may be required.
For malignant obstruction, recurrent cholangitis is common. Manegement is usually through STENT PLACEMENT. Although specific therapy chosen will depend on the patient’s life expectancy and the likelihood of stent occlusion.
Prognosis
With advances in treatment, overall mortality rate from cholangitis has dropped from 65% to 11% or less
However, while improved, mortality rates for severe acute cholangitis remains high at 20-30%
