Acute Cholangitis

Question 1

Acute cholangitis refers to infection of the … … characteristically resulting in pain, jaundice and fevers.

Answer 1

Acute cholangitis refers to infection of the biliary tree characteristically resulting in pain, jaundice and fevers.

Question 2

Acute … refers to infection of the biliary tree characteristically resulting in pain, jaundice and fevers.

Answer 2

Acute cholangitis refers to infection of the biliary tree characteristically resulting in pain, jaundice and fevers.

Question 3

Acute cholangitis almost always occurs due to bacterial infection secondary to … … The terms acute and ascending cholangitis can be used interchangeably.

Answer 3

Acute cholangitis almost always occurs due to bacterial infection secondary to biliary obstruction. The terms acute and ascending cholangitis can be used interchangeably.

Question 4

Biliary obstruction is often secondary to choledocholithiasis (… in the biliary tree) or biliary … (both benign and malignant).

Answer 4

Biliary obstruction is often secondary to choledocholithiasis (gallstones in the biliary tree) or biliary strictures (both benign and malignant).

Question 5

Acute cholangitis is a relatively … condition.

Answer 5

Acute cholangitis is a relatively uncommon condition.

Question 6

Acute cholangitis is a relatively uncommon condition - what is the median age? And is one gender more affected?

Answer 6

The exact incidence is unknown. The median presenting age is 50-60, affecting men and women equally. There appears to be greater incidence in Caucasians, Hispanics and Native Americans - following the distribution of gallstones.

Question 7

Acute cholangitis occurs after what procedure sometimes?

Answer 7

It occurs following ERCP in around 0.5 - 3%. Recurrent pyogenic cholangitis is seen in Southeast Asian populations.

Question 8

Recurrent pyogenic cholangitis is seen in … populations.

Answer 8

Recurrent pyogenic cholangitis is seen in Southeast Asian populations.

Question 9

Choledocholithiasis, stones in the bile duct, are the most common cause of acute …

Answer 9

Choledocholithiasis, stones in the bile duct, are the most common cause of acute cholangitis.

Question 10

Choledocholithiasis refers to gallstones within the bile ducts. It occurs in around …-…% of people with cholelithiasis (gallstones). It should be noted that not all patients with choledocholithiasis develop cholangitis, and such stones may be asymptomatic.

Answer 10

Choledocholithiasis refers to gallstones within the bile ducts. It occurs in around 10-20% of people with cholelithiasis (gallstones). It should be noted that not all patients with choledocholithiasis develop cholangitis, and such stones may be asymptomatic.

Question 11

Acute cholangitis occurs due to impaired drainage and bacterial overgrowth. It is the most common cause of ascending cholangitis, implicated in around …% of cases.

Answer 11

Acute cholangitis occurs due to impaired drainage and bacterial overgrowth. It is the most common cause of ascending cholangitis, implicated in around 80% of cases.

Question 12

Benign strictures, leading to obstruction, may occur in the biliary tree for numerous reasons:

(4)

Answer 12

Chronic pancreatitis
Iatrogenic injury (e.g. during cholecystectomy)
Radio / chemo-therapy
Idiopathic

Question 13

Primary sclerosing cholangitis is a chronic, progressive condition associated with … … It is characterised by inflammation and stricturing of bile ducts. Although the strictures are typically benign, patients are at increased risk of many cancers including cholangiocarcinoma, gallbladder cancer and hepatocellular carcinoma.

Answer 13

Primary sclerosing cholangitis is a chronic, progressive condition associated with ulcerative colitis. It is characterised by inflammation and stricturing of bile ducts. Although the strictures are typically benign, patients are at increased risk of many cancers including cholangiocarcinoma, gallbladder cancer and hepatocellular carcinoma.

Question 14

Primary … … is a chronic, progressive condition associated with ulcerative colitis. It is characterised by inflammation and stricturing of bile ducts. Although the strictures are typically benign, patients are at increased risk of many cancers including cholangiocarcinoma, gallbladder cancer and hepatocellular carcinoma.

Answer 14

Primary sclerosing cholangitis is a chronic, progressive condition associated with ulcerative colitis. It is characterised by inflammation and stricturing of bile ducts. Although the strictures are typically benign, patients are at increased risk of many cancers including cholangiocarcinoma, gallbladder cancer and hepatocellular carcinoma.

Question 15

Malignant biliary strictures may lead to acute …. Malignancies include cholangiocarcinoma, pancreatic cancer and gallbladder cancer.

Answer 15

Malignant biliary strictures may lead to acute cholangitis. Malignancies include cholangiocarcinoma, pancreatic cancer and gallbladder cancer.

Question 16

Other causes of acute cholangitis (excluding choledocholithiasis and malignant + benign strictures)

Answer 16

Post-ERCP (normally related to inadequate drainage)
Blocked biliary stent
Extrinsic compression
Blood clots
Parasites (e.g. Ascaris lumbricoides)

Question 17

Ascending cholangitis often presents with… (3)

Answer 17

Ascending cholangitis often presents with upper abdominal pain, jaundice and fevers.

Question 18

Post-ERCP (normally related to inadequate drainage)
Blocked biliary stent
Extrinsic compression
Blood clots
Parasites (e.g. Ascaris lumbricoides)
Can all cause what?

Answer 18

Acute cholangitis

Question 19

Ascending cholangitis was first described by Charcot as a life-threatening condition. We now know it may present with a wide spectrum of symptoms though fever, jaundice (may be sub-clinical) and pain are common. Two sets of symptoms are often described:

Charcot’s triad: RUQ pain, …, jaundice
Reynolds pentad: RUQ pain, …, jaundice, …, confusion

Answer 19

Charcot’s triad: RUQ pain, fever, jaundice

Reynolds pentad: RUQ pain, fever, jaundice, shock, confusion

Question 20

What is charcot’s triad?

Answer 20

Charcot triad is the classic picture of acute cholangitis - jaundice, fever, RUQ pain

Question 21

What is reynold’s Pentad?

Answer 21

Reynolds pentad is a collection of signs and symptoms suggesting the diagnosis obstructive ascending cholangitis, a serious infection of the biliary system.

Question 22

In acute cholangitis, not all features may be present, … triad is seen in around 50-70% of cases.

Answer 22

Not all features may be present, Charcot’s triad is seen in around 50-70% of cases.

Question 23

Symptoms of acute cholangitis (4)

Answer 23

RUQ / epigastric pain
Fevers
Malaise
Nausea/vomiting

Question 24

Signs of acute cholangitis (5)

Answer 24

RUQ / epigastric tenderness
Pyrexia
Jaundice
Hypotension (severe cases)
Confusion (severe cases)

Question 25

This shows the signs and symptoms of…

Answer 25

Acute cholangitis

Question 26

Acute cholangitis is most commonly investigated with USS, CT abdomen/pelvis and ….

Answer 26

Acute cholangitis is most commonly investigated with USS, CT abdomen/pelvis and MRCP.

Question 27

Acute cholangitis is most commonly investigated with …, CT abdomen/pelvis and MRCP.

Answer 27

Acute cholangitis is most commonly investigated with USS, CT abdomen/pelvis and MRCP.

Question 28

Acute cholangitis - Blood tests reveal elevated inflammatory markers and an … picture (raised bilirubin and ALP, though transaminases may also be elevated) on liver function tests.

Answer 28

Acute cholangitis - Blood tests reveal elevated inflammatory markers and an obstructive picture (raised bilirubin and ALP, though transaminases may also be elevated) on liver function tests.

Question 29

Acute cholangitis - Blood tests reveal elevated inflammatory markers and an obstructive picture (raised bilirubin and …, though transaminases may also be elevated) on liver function tests.

Answer 29

Acute cholangitis - Blood tests reveal elevated inflammatory markers and an obstructive picture (raised bilirubin and ALP, though transaminases may also be elevated) on liver function tests.

Question 30

Bedside tests for acute cholangitis

Answer 30

Observations
BM
Urine dip
Pregnancy test (any woman of child-bearing age)

Question 31

Blood tests for acute cholangitis

Answer 31

Full blood count
Urea & electrolytes
CRP
Liver function tests
Amylase

Question 32

Imaging for acute cholangitis?

Answer 32

Ultrasound: allows assessment of the gallbladder for gallstones and assessment of the CBD

Computed tomography: good visualisation of the biliary tree, including the distal portion, used where USS inconclusive, to evaluate for abnormal lesions/tumours or where other diagnoses are suspected.

MRCP: Magnetic resonance cholangiopancreatography offers excellent visualisation of the biliary tree. Often used where CT/USS are inconclusive.

Question 33

…. offers excellent visualisation of the biliary tree. Often used where CT/USS are inconclusive.

Answer 33

MRCP

Question 34

… involves the endoscopic intubation of the ampulla of Vater. It offers excellent views of the biliary tree whilst allowing therapeutic intervention such as drainage. ERCP is now generally a therapeutic rather than diagnostic intervention.

Answer 34

ERCP: Endoscopic retrograde cholangiopancreatography involves the endoscopic intubation of the ampulla of Vater. It offers excellent views of the biliary tree whilst allowing therapeutic intervention such as drainage. ERCP is now generally a therapeutic rather than diagnostic intervention.

Question 35

Patients with an infected, obstructed biliary system require urgent …

Answer 35

Patients with an infected, obstructed biliary system require urgent drainage.

Question 36

Biliary drainage

Drainage of the infected biliary system is key to effective management. It is now achieved utilising non-operative techniques (except in very rare cases). There are two main options:

Answer 36

ERCP: Typically first line and conducted by the gastroenterologists, it relies on the passage of an endoscope into the duodenum and intubation of the ampulla of Vater. A dye may then be injected which when combined with fluoroscopy allows visualisation of the biliary tree. It can be used to retrieve stones, perform a sphincterotomy and place a biliary stent to relieve the obstructed system. Cytology and biopsy samples may also be taken if relevant. Complications include acute pancreatitis, duodenal perforation and gastrointestinal bleeding.
PTC: Percutaneous transhepatic cholangiography may be used if ERCP fails, is unavailable or inappropriate. Conducted by interventional radiologists it involves percutaneous puncture to access the biliary tree through the liver. PTC allows for drainage of the biliary system, stone retrieval and stent placement. The major risk is haemobilia (bleeding into the biliary system).

Question 37

ERCP vs PTC for biliary drainage - what is typically first line?

Answer 37

ERCP: Typically first line and conducted by the gastroenterologists, it relies on the passage of an endoscope into the duodenum and intubation of the ampulla of Vater. A dye may then be injected which when combined with fluoroscopy allows visualisation of the biliary tree. It can be used to retrieve stones, perform a sphincterotomy and place a biliary stent to relieve the obstructed system. Cytology and biopsy samples may also be taken if relevant. Complications include acute pancreatitis, duodenal perforation and gastrointestinal bleeding.
PTC: Percutaneous transhepatic cholangiography may be used if ERCP fails, is unavailable or inappropriate. Conducted by interventional radiologists it involves percutaneous puncture to access the biliary tree through the liver. PTC allows for drainage of the biliary system, stone retrieval and stent placement. The major risk is haemobilia (bleeding into the biliary system).

Question 38

Is a cholecystectomy done after acute cholangitis?

Answer 38

Elective cholecystectomy is indicated in those with gallstones after a period of recovery.

Question 39

A 77-year-old woman is admitted under the surgical team with abdominal pain and fevers. She underwent laparoscopic cholecystectomy for gallstones 5 years ago. Her only other background history is breast cancer 10 years ago. On examination, there is evidence of right upper quadrant pain and mild scleral jaundice. The surgical team arranges an urgent CT abdomen and pelvis. Urgent bloods are shown:

Hb 120 (135-165 g/L)

WCC 16.1 (4.0-11.0 x10^9/L)

Urea 6.8 (2.5-7.0 mmol/L)

Creatinine 83 (60-110 umol/L)

Bilirubin 45 (1-22 umol/L)

ALT 120 (5-35 U/L)

ALP 326 (45-105 U/L)

Amylase 120 (60-180 U/L)

What is the most likely diagnosis?
A	Acute cholecystitis
B.    Acute cholangitis 
C	Acute pancreatitis
D	Peptic ulcer disease
E	Biliary colic

Answer 39

B

This likely represents acute cholangitis due to raised inflammatory markers, jaundice and previous gallstone disease.

Acute cholangitis is characterised by Charcot’s triad of fever, right upper quadrant pain and jaundice. It is commonly secondary to gallstones, which can still occur in patients who have undergone a cholecystectomy. The absence of a gallbladder means the patient does not have acute cholecystitis. Rarely, inflammation or infection of a gallbladder remnant can occur following surgery.

The normal amylase is useful to exclude pancreatitis.

Question 40

A 51-year-old man presents to accident and emergency with fever and rigors. He has been unwell for the last 24 hours with intermittent abdominal pain. Today he noticed his eyes becoming yellow and started to develop high fevers. His partner measured his temperature at home as 39.2º. He has no significant background history and does not take regular medications. On examination, he has right upper quadrant tenderness with guarding. A CT is performed, which shows evidence of an obstructing gallstone within the common bile duct and marked dilatation of the common bile duct and intrahepatic ducts. He is started on intravenous antibiotics and intravenous fluids.

What is the most appropriate next step in management?

A Urgent open cholecystectomy
B Outpatient laparoscopic cholecystectomy
C Percutaneous cholecystostomy
D Urgent referral for endoscopic retrograde cholangiopancreatography (ERCP)
E Whipple’s procedure

Answer 40

D - This case repesents acute cholangitis secondary to choledocholithiasis (i.e. gallstones) within the common bile duct causing obstruction.

Question 41

ERCP - what is it?

Answer 41

The procedure relies on the passage of an endoscope into the duodenum and intubation of the ampulla of Vater. A dye may then be injected which when combined with fluoroscopy allows visualisation of the biliary tree. It can be used to retrieve stones, perform a sphincterotomy and place a biliary stent to relieve the obstructed system. Cytology and biopsy samples may also be taken if relevant.

Question 42

Complications of ERCP include … (3)

Answer 42

acute pancreatitis, duodenal perforation, and gastrointestinal bleeding.

Question 43

After cholangitis is treated, patients can be referred for elective … if secondary to gallstones. Prior to cholecystectomy, it is key that … stones are excluded. If present, they will need to be removed which is most commonly through ERCP.

Answer 43

After cholangitis is treated, patients can be referred for elective cholecystectomy if secondary to gallstones. Prior to cholecystectomy, it is key that CBD stones are excluded. If present, they will need to be removed which is most commonly through ERCP.

Question 44

Percutaneous cholecystostomy is an interventional radiology procedure that involves the insertion of a … into the gallbladder. It may be offered to patients with a gallbladder … that is not suitable for ‘hot’ laparoscopic cholecystectomy

Answer 44

Percutaneous cholecystostomy is an interventional radiology procedure that involves the insertion of a drain into the gallbladder. It may be offered to patients with a gallbladder empyema that is not suitable for ‘hot’ laparoscopic cholecystectomy