Acute Cholangitis Flashcards
Define acute cholangitis
- Infection of the biliary tree, obstruction requiring prompt treatment
- Previously known as ascending cholangitis
Presenting symptoms of acute cholangitis
- Charcot’s triad= fever, jaundice (obstructive)
- RUQ pain (50-70%)
- Sepsis- toxic cholangitis, hypotension, multi-organ failure, mental status changes (poor prognosis)
- Pale stools (due to deficient bile secretion)
- RUQ tenderness on examination guarding
- Pruritus (itching with liver disease)
- Older = non-specific/ non-localising complaints e.g no fever
- may have deceptively normal signs until late
- Nausea, vomiting, generalised abdo pain (ascaris lumbricodis)
- not classic Murphy’s sign
Epidemiology of acute cholangitis
- uncommon
- 1% of those with cholelithiasis
- m:f
- 50-60 yrs
- more common in Latin Americans and American Indians
- 1-3% develop cholangitis after endoscopic retrograde cholangiopancreatogrpahy (poor biliary drainage)
- recurrent oriental pyogenic cholangitis more common in SE Asia, associated with intrahepatic stone disease
Risk factors of acute cholangitis
- > 50
- Cholelithiasis (gallstones in bile duct)
- Benign/malignant stricture
- Post procedure injury of bile ducts (endoscopic, radiological- poor drainage/contamination)
- Prior ERCP
- Hx of primary/secondary sclerosing cholangitis (scarred bile ducts)
- HIV infection/ cholangiopathy
- biliary disease
Aetiology/causes of acute cholangitis
- Cholelithiasis (GS) leading to choledocholithiasis (GS in BD) and biliary obstruction
- Latrogenic biliary duct injury (surgery) = benign strictures = obstruction
- Chronic pancreatitis = benign stricture
- Radiation induced biliary injury
- Systemic chemotherapy (e.g fluorodeoxyuridine)
- Sclerosing cholangitis (primary/secondary) cause 24% cases
- Acute pancreatitis
- Parasite entry (Ascaris lumbricoides = nausea, vomiting, generalised abdo pain, or Fasciola hepatica)
- Extrinsic compression of biliary tree due to adenopathy, papilla, blood clots, sump syndrome (rare complication after choledochoduodenostomy where distal common bile duct traps food particles = infection)
- Cholangiocarcinoma, primary gallbladder cancer, ampullary cancer, pancreatic cancer, primary small bowel cancer = malignant biliary strictures
Pathophysiology of acute cholangitis
Obstruction of common bile duct = bacterial seeding of the biliary tree, via portal vein = acute cholangitis
-Sludge forms, growth medium for bacteria = pressure increases = pressure gradient promotes bacteria into bloodstream = sepsis
Diagnosis of acute cholangitis
-Use NEWS2 to assess deterioration risk due to sepsis
-Severe if hypotensive/mental status changes
-Transabdominal US as initial imaging (>90% accurate in detecting bile duct dilation, common bile duct stones) if RUQ pain
-Subsequent abdo CT with intravenous contrast if US inconclusive (abdo CT often done in patients with sepsis to rule out other causes of sepsis), better than US for visualising distal CBD & defining neoplasm extent
-consider MRCP or endoscopic US (before definitive treatment if) US and CT negative and high clinical suspicion remains for cholangitis
(endoscopic ultrasound EUS is as accurate as MRCP for the detection of choledocholithiasis but less used, if suspicion of CBD stones low, if + = ERCP performed)
- Initial blood tests - FBC, Coagulation profile (PT raised- decreased platelets), CRP, LFTs (hyperbilirubinaemia, raised serum transaminases AST,ALT, alkaline phosphatase), U&Es (including creatinine, Mg/K decrease), blood culture (bacteria usually gram negative)
- WBC>10*9/L
- K may be decreased
- Arterial blood gas ABG, lactate if sepsis suspected
- Metabolic acidosis in severe states
Treatment of acute cholangitis
- method of biliary decompression- diagnostic or therapeutic
- ERCP best first intervention - arrange early if Hx of biliary disease, other RFs (diagnostic and therapeutic for biliary stone extraction)
- Percutaneous trans-hepatic cholangiography PTC if ERCP unavailable/impossible (gastric bypass route, oesophageal/pyloric/duodenal stricture) - biliary catheter placed, stone extraction- often require ERCP after to clear the biliary tree and/or place internal stents
- EUS for direct bile duct access and decompression via transluminal stenting
Initial Stabilisation
- broad-spectrum intravenous antibiotics - piperacillin/tazobactam & imipenem/cilastatin, cefuroxime plus metronidazole- and intravenous hydration
- correct electrolyte imbalances, coagulation abnormalities, analgesia (morphine sulfate/oxycodone + paracetamol)
Biliary decompression (again)
- ERCP (w/sphincterotomy) and stent
- PTC if ERCP unsuitable
- Endoscopic lithotripsy (waves fragment stones)
Surgical methods
- Choledochotomy with T-tube placement
- Cholecystectomy with CBD exploration
- elective if patient stable
Switch to specific antibiotics
-replace IV AB with oral therapy after surgery
Ongoing management
- subsequent cholecystectomy for patients who had cholangitis with subsequent cholelithiasis
- refer primary sclerosing cholangitis PSC to hepatologist (tissue sampling for cholangiocarcinoma)
- HIV refer to HIV specialist
- continue to monitor symptoms, blood. LFTs
- IV K/Mg
Non-operative Decompression
-emergenct manner
-Endoscopic lithotripsy for larger stones to faciliate removal
-ERCP
-PTC
(-nasobiliary drains, anti-reflux biliary stents being developed)
Other differentials than acute cholangitis
Acute cholecystitis - positive murphy sign
Peptic ulcer disease- symptoms improve with food/antacids, LFT normal
Acute pancreatitis- pain more severe, amylase greater than for cholangitis, lipase raised more specific to pancreas than amylase, CT shows stranding around pancreas
Hepatic abscess- hepatomegaly, bile ducts less likely dilated
Acute pylelonephritis- flank pain, costovertebral angle tenderness
Acute appendicitis - McBurney’s point tenderness, Rovsing’s sign, CT scan = thickened appendix
Right lower lobe pneumonia - Hx of cough, SOB, crackles, CT scans shows LL consolidation
HELLP syndrome of pre-eclampsia - haemolytic anaemia, lactate dehydrogenase increased (marker of haemolysis), proteinuria
Criteria/Grading for acute cholangitis
A. Systemic inflammation A-1 = fever/chills
A-2 = lab data showing inflammatory response
B. Cholestasis B-1 = Jaundice
B-2 lab data showing abnormal LFTs
C. Imaging C-1 = biliary dilation
C-2 = evidence of the aetiology on imaging (stricture, stone, stent)
Suspected diagnosis: one item in A & from B/C
Definite diagnosis: one item in A & from B & from C
Other: RUQ pain, Hx
Grade III (severe) is onset of dysfunction in at least one organ/system:
- CDV- hypotension requiring dopamine >5mg/kg/min or noadrenaline
- Neurological- consciousness
- Respiratory- PaO3/FiO2 ratio <300
- Renal - oliguria, creatine >177
- Hepatic - PT-INR >1.5
- Haematological- plt <100*9/L
Grade II (moderate) is 2 of:
- abnormal WBC >129/L or <49/L
- high fever >39
- > 75 yrs
- hyperbilirubinaemia >85mmol/L
Grade I (mild)
Early biliary drainage, antimicrobial administration for all Grades
Overall treatment algorithm for acute cholangitis
1st line - IV antibiotics + intensive med management
Consider lithotripsy, analgesic + paracetamol
Biliary decompression: non-operative- ERCP,PTC
Surgical
-laparoscopic choledochotomy with T-tube placement or cholecystectomy with CBD exploration
Specific antibiotics
Ongoing with choledocholithiasis, PSC, or HIV cholangiopathy
-refer for follow-up med/surgical care
Prevention of acute cholangitis
- prophylactic antibiotics in ERCP to reduce risk of post-ERCP cholangitis
- ensure adequate biliary drainage in procedures
Complications with acute cholangitis
Medium
-Acute Pancreatitis- distal common bile duct stones that lead to cholangitis can also lead to AP via obstruction of the pancreatic duct of the common channel joining the CBD and the pancreatic duct. AP is also a complication of ERCP
Low
-inadequate biliary drainage following endoscopy/radiology/surgery
-hepatic abscess, more common in PSC, secondary sclerosing cholangitis, post-surgical biliary anatomy changes
Predictive factors for poor prognosis
- hyperbilirubinaemia
- high fever
- leukocytosis
- older age
- hypoalbuminaemia
- requiring surgery worse tthan non-operative procedures
- delayed decompression
