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
Salient features of this stem are the Charcot’s triad, along with dark urine and pale stools, all in keeping with an obstructive jaundice, likely acute cholangitis. This requires urgent treatment to prevent severe complications. DDx to consider include other causes of obstructive jaundice;

• choledocolithiasis
• Mirrizzi syndrome + cholecystitis
• neoplasia: cholangiocarcinoma, HCC, HOP tumour
• primary sclerosis cholangitis
• cholecystitis
• biliary colic
• biliary tree strictures

Management

• urgent assessment with targeted Hx/Ex/Ix, referral to gen surg for review, initiate any resuscitative measure in acute setting as required. Diagnose with Abdo US, MRCP and supportive bloods.
• likely IV ABx to prevent serious complication (sepsis, perf), or as bridge to further surgery if non-improvement with ERCP to drain the CBD and potentially stent - these management decision ultimately made by gen surg treating team.

Question 2

Acute cholangitis - History

Answer 2

History

• sx: fever, pain (SOCRATES), jaundice (degree of). When noticed stool.urinary changes, pruritus?
• previous gallstones? biliary colic?
• RISKS: age >50, history of gall stones, PSC/IBD, previous abdo surgery/ERCPs
• SNAP, PMHx, meds + allergies

Question 3

Acute cholangitis - Examination

Answer 3

Examination

• General appearance + vital signs
• Abdo examination: RUQ pain, signs of liver failure, jaundice, peritonism
• systems review: mets, infection

Question 4

Acute cholangitis - Investigations

Answer 4

Investigations

• bedside: urinalysis, VBG
• bloods: LFTs, FBC, UEC, CMP, ESR/CRP, serum bilirubin, blood cultures, coags
• Imaging: abdo US (dilated bile duct, stones), MRCP (not necessarily indicated if cholangitis suspected, ERCP (diagnostic and therapeutic)

Question 5

Acue Cholangitis - management

Answer 5

Management

• Acute assessment for any HD instability
• Call senior colleagues, arrange urgent gen surg review

Supportive

• antipyretics
• antiemetics
• analgesia
• fluids, electrolyte balancing
• NBM if for theatres

Definitive:

• IV antibiotics (pip-taz, but as per eTG) broad spectrum, then directed therapy once sensitivities return.
• ERCP with CBD drainage, +/- stenting
• laparoscopic choledocotomy if non-operative approach not viable

If neoplasia, then require MDT referral and ongoing management input