**ACC (Y4)** "Abdominal pain": Biliary tract infections (acute cholecystitis, cholangitis)

Question 1

Acute cholecystitis Vs Acute cholangitis

Answer 1

Acute cholecystitis: inflammation of the gallbladder wall - caused by blockage of bileduct (stones usually)

Acute cholangitis: inflammation in the bile ducts/infection of biliary tree, caused by a combination of both biliary outflow obstruction and biliary infection.

Question 2

what is calculous cholecystitis?

Answer 2

Acute cholecystitis (inflammation of gallbladder wall) caused by gallstones

Question 3

what is acalculous cholecystitis?

Answer 3

Acute cholecystitis (inflammation of gallbladder wall) NOT caused by gallstones

e.g. One scenario where this may occur is in patients on total parental nutrition or having long periods of fasting (for example in ICU for other serious conditions), where the gallbladder is not being stimulated by food to regularly empty, resulting in a build-up of pressure.

Question 4

presentation of acute cholecystitis

Answer 4

pain in the right upper quadrant (RUQ). This may radiate to the right shoulder.

• Fever
• Nausea
• Vomiting
• Tachycardia (fast heart rate) and tachypnoea (raised respiratory rate)
• Right upper quadrant tenderness
• Murphy’s sign (palpate RUQ/right subcostal area, ask pt to breathe in, pain on inspiration = positive murphy’s sign) (from gallbladder touching dr hand)
• Raised inflammatory markers and white blood cells

Question 5

How to look for murphy’s sign? and what is a positive murphy’s sign suggestive of?

Answer 5

Murphy’s sign is suggestive of acute cholecystitis:

• Place a hand in RUQ and apply pressure
• Ask the patient to take a deep breath in
• The gallbladder will move downwards during inspiration and come in contact with your hand
• Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration

Question 6

how to confirm a diagnosis of acute cholecystitis?

Answer 6

Imaging:

1st: abdo ultrasound, signs incl:
- Thickened gallbladder wall
- Stones or sludge in gallbladder
- Fluid around the gallbladder

2nd: Magnetic resonance cholangiopancreatography (MRCP) may be used to visualise the biliary tree in more detail if a common bile duct stone is suspected but not seen on an ultrasound scan (e.g., bile duct dilatation or raised bilirubin).

Bloods:
- WBC, CRP, serum amylase

Question 7

how do you manage a pt with acute cholecystitis?

Answer 7

conservative:

• NBM
• IV fluids
• Antibiotics (as per local guidelines)
• NG tube if required for vomiting

Surgical:
Endoscopic retrograde cholangio-pancreatography (ERCP) (remove stones)

Cholecystectomy (remove gallbladder)

Question 8

Cholecystectomy vs Cholecystostomy

Answer 8

Cholecystectomy (to remove the gallbladder)

Cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)

Question 9

what is Gallbladder empyema?

Answer 9

infected tissue and pus collecting in the gallbladder.

Management involves IV antibiotics and one of two main options:

• Cholecystectomy (to remove the gallbladder)
• Cholecystostomy

Question 10

what are the most common organisms to cause Acute cholangitis?

Answer 10

1. Escherichia coli
2. Klebsiella species
3. Enterococcus species

Question 11

What does Acute cholangitis present as?

Answer 11

Charcot’s Triad

1. Right upper quadrant pain
2. Fever
3. Jaundice (raised bilirubin)

NB:If you see a patient in your exams with fever, raised bilirubin and right upper quadrant pain, you know the diagnosis is acute cholangitis.

Other symptoms include: pruritus (itching), pale stools, dark urine and nausea/vomiting.

It is also important to ask about a history of gallstone disease and any recent biliary procedures (e.g. ERCP).

Question 12

how to manage Acute cholangitis?

Answer 12

Patients need acute management of sepsis and acute abdomen, including:

• Nil by mouth
• IV fluids
• Blood cultures
• IV antibiotics (as per local guidelines)
• Involvement of seniors and potentially HDU or ICU

Question 13

which imaging would you use to common bile duct (CBD) stones and cholangitis?

Answer 13

(from least to most sensitive) are:

• Abdominal ultrasound scan
• CT scan
• *** Magnetic resonance cholangio-pancreatography (MRCP)
• *** Endoscopic ultrasound

Question 14

what is an endoscopic retrograde cholangio-pancreatography (ERCP)?

Answer 14

An ERCP is required to remove stones blocking the bile duct.

• inserting an endoscope down the oesophagus, to the duodenum and the opening of the common bile duct (the sphincter of Oddi).
• This gives the operator access to the biliary system.

A number of procedures can be performed during an ERCP:

• Cholangio-pancreatography
• stone removal
• biliary stenting
• biopsy

Question 15

what are some risk factors for the development of cholangitis?

Answer 15

• gallstones
• latrogenic biliary injury
• tumours
• sclerosing cholangitis
• biliary strictures
• parasitic infections

Question 16

what is raynaud’s pentad?

Answer 16

The presence of hypotension and confusion alongside the features of Charcot’s triad may be referred to as Raynaud’s pentad.

Patients with signs of systemic infection typically have a poorer prognosis.

Question 17

pt has RUQ pain, no fever, no jaundice - diagnosis?

Answer 17

Biliary colic

Question 18

pt has RUQ pain and fever, no jaundice - diagnosis?

Answer 18

Cholecystitis

Question 19

pt has RUQ pain and fever, and jaundice - diagnosis?

Answer 19

Cholangitis

Charcot’s triad

Question 20

complications of cholangitis?

Answer 20

• acute pancreatitis (stones can lead to blockage of pancreatic duct)
• hepatic abscess formation

Question 21

what are some signs of systemic infection?

Answer 21

rigors,
hypotension,
confusion
tachycardia.