Acute cholangitis

Question 1

A 78 year-old-woman presents with a 48-hour history of right upper quadrant pain, jaundice and fever. There has been dark urine and pale stools. The gallbladder is not palpable on examination. Outline your management of this patient.

Answer 1

Impression
Acute cholangitis (Ascending cholangitis) given Charcot’s triad (RUQ pain, fever, obstructive jaundice). This is a surgical emergency. Key differentials I would consider include;
- choledocolithiasis
- PSC
- cholangiocarcinoma
- acute cholecystitis (wouldn’t expect jaundice)

Concerned about complications of gram -ve bacteraemia and septic shock. would conduct A to E assessment initially if patient presents as acutely unstable and institute appropriate resuscitative management initially.

Question 2

Acute cholangitis - History

Answer 2

History

• sx: SOCRATES, bowel changes, infective sx (fevers)
• PMHx: gallstones disease, prev biliary colic, IBD +/- PSC,
• Medications
• SNAP - particular focus on alcohol

Question 3

Acute cholangitis - Examination

Answer 3

Examination

• General appearance + vital signs (temp)
• Gastro-intestinal examination: focal tenderness, rebound, bowel sounds, Murphy’s sign, hepatomegaly, stigmata of chronic liver disease (gynaecomastia, nail changes,

Question 4

Acute cholangitis - Investigations

Answer 4

Investigations
- Key/diagnostic: U/S abdo, MRCP, ERCP (diagnostic and therapeutic with biliary drainage), other abdominal imaging protocols

• bedside: vitals, VBG, UA
• Bloods: LFTs (Cholestatic picture), CRP/ESR, FBC, UEC, Blood cultures, lipase, hepatitis serology?
  o consider the rest of the septic screen.
• Imaging: abdo US, Abdo CT, MRCP

Question 5

Acute cholangitis - Management

Answer 5

Management
- depends on status. If acutely unwell/toxic, start immediate empirical Abx and fluid resus, call for senior help, arrange gen surg consult for triaging and advice re definitive management

Definitive

• empirical Abx (IV Gent + Amoxicillin OR Ampicillin)
• biliary drainage: via ERCP, percutaneous or surgically via laparoscopic/open common bile duct exploration

Supportive

• analgesia and antipyretics
• fluids
• NBM