Acute Cholangitis

Question 1

What is cholangitis?

Answer 1

Infection of biliary tree

Commonly caused by obstruction

Question 2

What is Charcot’s triad?

Answer 2

Fever
Jaundice
RUQ pain
indicative of acute cholangitis

Question 3

What are the most common causes of acute cholangitis?

Answer 3

Choledocholithiasis (gallstones)

Benign/malignant strictures

Question 4

What happens when acute cholangitis is left untreated?

Answer 4

Sepsis
Shock
Vascular collapse
Multi-organ failure
Death

Question 5

What are the risk factors for acute cholangitis?

Answer 5

50+
History of cholelithiasis
1ry or 2ry sclerosing cholangitis
Stricture of biliary tree
Post-procedure injury of bile ducts

Question 6

Difference in RUQ for acute cholangitis and Murphy’s sign?

Answer 6

This is more diffuse

Question 7

What are some other diagnostic factors for acute cholangitis?

Answer 7

Common:
Pale stools
Pruritus (Itchy skin)

Uncommon:
Hypotension
Mental status change

Question 8

First line investigations for acute cholangitis?

Answer 8

FBC - raised WCC
Serum Urea - raised
Serum Cr - raised
ABG

Question 9

What investigations should be considered for acute cholangitis?

Answer 9

If US is -ve –>
Abdo CT with IV contrast:
Can visualise bile duct dilation

If CT is -ve –>
MRCP - Magnetic resonance cholangiopancreatography: Look for mass on biliary tree/stricture/choledocholithiasis

If ERCP is unavailable –>
PTC - Percutaneous trans-hepatic cholangiogrpahy: Look for stones

EUS - Endoscopic ultrasonography: Look for common bile duct (CBD) stones/ampullary, pancreatic or biliary masses

Question 10

What might severe acute cholangitis show on an ABG?

Answer 10

Low bicarbonate with a raised anion gap
Metabolic acidosis
Raised lactate

Question 11

What other investigations can be considered for AC?

Answer 11

Transabdominal US - look for dilated bile duct and common bile duct stones

Question 12

What is the best first intervention in AC?

Answer 12

ERCP - endoscopic retrograde cholangiopancreatography

Used for stone extraction

Also a diagnostic tool

Question 13

What is the first line treatment for someone acutely unwell with AC?

Answer 13

IV Ab + intensive medical manangement (4-7 days)

With biliary decompression: non-operative

Consider Lithotripsy

Consider opioid analgesia + paracetamol

Question 14

What is lithotripsy?

Answer 14

It uses shock waves or a laser to break down stones in the kidney, gallbladder, or ureters. The remaining particles of small stones will exit the body when the person urinates.

Question 15

What is indicative of a patient deteriorating?

Answer 15

persistent abdominal pain, hypotension despite intravenous fluid administration, fever >39°C (102°F), or a worsening confusional state

Question 16

How can biliary decompression be achieved non-surgically?

Answer 16

ERCP and placement of drainage stent

PTC for those who are poor ERCP candidates

Question 17

What analgesia can be used in AC?

Answer 17

Oxycodone: 5 mg orally (immediate-release) every 4-6 hours initially

Morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially

AND

Paracetamol: 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours

Question 18

How can biliary decompression be achieved surgically?

Answer 18

Laparoscopic choledochotomy with T-tube placement or cholecystectomy with common bile duct exploration

Question 19

What primary Abs are considered?

Answer 19

piperacillin/tazobactam
OR
imipenem/cilastatin
OR
cefuroxime and metronidazole