Acute cholangitis

Question 1

What is cholangitis?

1 - infected gall bladder
2 - gall bladder cancer
3 - stasis of bile and infection in the bile ducts
4 - gallstones

Answer 1

3 - stasis of bile and infection in the bile ducts

• cholan = biles ducts
• itis = inflammation

Question 2

Why is it called ‘ascending’ or ‘acute’ cholangitis?

1 - bacteria ascend up intestines into bile ducts
2 - symptoms present in an abrupt acute fashion
3 - left and right bile ducts (most superior) become infected)

Answer 2

1 - bacteria ascend up intestines into bile ducts

• normally does not occur as bile move down biliary tree and flushes bacteria back into duodenum

Question 3

15% of the UK population have gallstones. Of this 15% what % will develop acute cholangitis?

1 - 0.9%
2 - 9%
3 - 19%
4 - 90%

Answer 3

2 - 9%

• 1% of patients develop acute cholangitis following ERCP

Question 4

Is acute cholangitis more common in men or women?

Answer 4

• same risk

Question 5

What is the median age where acute cholangitis occurs?

1 - 15-30 y/o
2 - 25-40 y/o
3 - 35-50 y/o
4 - 50-60 y/o

Answer 5

4 - 50-60 y/o

Question 6

In normal physiology, which of the following is NOT a barrier to bacteria ascending up the biliary tree and causing infection?

1 - bacteriostatic activity of bile salts
2 - pancreatic juice
3 - sphincter of Oddi
4 - bile flushing
5 - secretory IgA and biliary mucous limit adherence to biliary tree

Answer 6

2 - pancreatic juice

Question 7

What is the most common cause of ascending cholangitis?

1 - bile duct stents
2 - biliary calculi
3 - benign biliary stricture
4 - biliary malignancy
5 - ERCP complication

Answer 7

2 - biliary calculi

• malignancy of any part of the biliary system accounts for 10-30% of cases with acute cholangitis

Question 8

Gallstones blocking the common bile duct can cause ascending cholangitis. Therefore, it is important to acknowledge the risk factors associated with gallstones. The 5 Fs can help, which is not one of these?

1 - Female
2 - Fertile
3 - Fair skin
4 - Festering
5 - Forty
6 - Fat

Answer 8

4 - Festering

Question 9

In addition to the 5F for increasing the risk of gallstones, which can therefore increase the risk of acute cholangitis, which of the following is NOT a classical risk factor for acute cholangitis?

Question 10

What is the most common bacteria species found in samples in the biliary tree in patients with ascending cholangitis?

1 - E coli
2 - Klebsiella
3 - Enterococcus
4 - Staphylococcus Aureus

Answer 10

1 - E coli

• accounts for 25-50%

Question 11

Ascending cholangitis can be very dangerous and cause septic shock. How does bacteria enter the circulatory system from the bile tree?

1 - moves up into liver and into inferior vena cava
2 - high pressure in bile ducts creates spaces between cells allowing bacteria into blood
3 - moves into gall bladder and into the cystic artery

Answer 11

2 - high pressure in bile ducts creates spaces between cells allowing bacteria into blood

• called translocation

Question 12

Patients with ascending cholangitis typically present with charcot’s triad. Which of the following is NOT part of this triad?

1 - fever
2 - right hypochondriac pain
3 - bowel obstruction
4 - jaundice

Answer 12

3 - bowel obstruction

Question 13

Patients with ascending cholangitis typically present with charcot’s triad. Which includes fever, right hypochondriac pain and jaundice. When a patient is suspected of having septic shock, 2 additional variables are added to charcots triad and is called Reynolds pentab. Which 2 of the following along with charcots triad make up Reynolds pentab?

1 - hypertension
2 - hypotension
3 - confusion
4 - hyperglycaemic

Answer 13

2 - hypotension
3 - confusion

Question 14

In all patients with suspected acute cholangitis, what imaging modality is often used?

1 - ultrasound
2 - MRI
3 - CT
4 - X-ray

Answer 14

1 - ultrasound

• investigate for bile duct dilation and/or stones
• if ultrasound and CT are normal we perform an MRCP

Question 15

In patients suspected acute cholangitis, with fever, abdominal pain, jaundice (Charcot’s triad), and abnormal liver tests, what would the next investigation be?

1 - abdominal ultrasound
2 - MRCP
3 - ERCP
4 - drainage of biliary tree

Answer 15

3 - ERCP

• gold standard for diagnosis

Question 16

In patients with suspected acute cholangitis, we need to conduct laboratory tests. Which of the following is not typically performed?

1 - FBC
2 - U&E
3 - CRP
4 - prothrombin time (PT), and PT-international normalised ratio
5 - urinalysis
6 - LFTs

Answer 16

6 - urinalysis

• FBC = increased WBC
• U&E = raised urea and creatinine suggest organ damage
• CRP = raised in infection
• PT and PT-INR ratio = distorted in hepatic disease
• LFTs = bilirubin, GGT, ALP

Question 17

In a patient who is suspected of having acute cholangitis, in addition to the usual blood biochemistry measures, which 2 of the following must also be conducted?

1 - pregnancy test
2 - blood culture
3 - ABG
4 - antibody test

Answer 17

1 - pregnancy test
2 - blood culture

Question 18

Which of the following is NOT a typical differential of acute cholangitis?

1 - acute cholecystitis (gall bladder inflammation)
2 - biliary leak
3 - acute pancreatitis
4 - liver abscess
5 - ileus

Answer 18

5 - ileus

Question 19

In a patient with acute cholangitis which 2 of the following should be conducted as soon as possible?

1 - nasal gastric tube (NGT)
2 - IV fluid and electrolyte resuscitation
3 - antibiotics
4 - analgesia
5 - reduction/reversal of intussusception

Answer 19

2 - IV fluid and electrolyte resuscitation
4 - analgesia

• empirical antibiotics can be given, BUT following blood culture or bile sample these may need to be changed

Question 20

What is the conservative management of a patient with acute cholangitis?

1 - fluid and electrolyte resuscitation+antibiotics
2 - MRCP
3 - ERCP
4 - drainage

Answer 20

1 - fluid and electrolyte resuscitation+antibiotics

• 70-80% of patients respond to this
• drainage may be used if not

Question 21

If possible, what is the first line for drainage of the biliary tree in a patient with acute cholangitis?

1 - ERCP
2 - endoscopic ultrasonography-guided biliary
3 - laparotomy

Answer 21

1 - ERCP

• sphincterotomy is performed opening the common bile duct and bile stones removed

Question 22

In addition to drainage (ERCP) other treatments can potentially be used to remove the gallstones that are blocking the common bile duct in a patient with acute cholangitis. Which one of the following is generally reserved for if all other methods have failed or are not possible?

1 - lithotripsy shock waves
2 - percutaneous drainage
3 - laparotomy
4 - stent insertiot

Answer 22

3 - laparotomy

Question 23

Once ascending cholangitis has settled and gallstones are the problem, what are patients normally advised to do?

1 - weight loss
2 - change medications
3 - modify diet
4 - undergo cholecystectomy

Answer 23

4 - undergo cholecystectomy

• essentially reduced the recurrence of acute cholangitis

Question 24

The following are all complications of acute cholangitis:

• if sepsis ensures, liver abscesses and liver failure can follow
• bacteraemia and Gram-negative sepsis
• septic shock, acute kidney injury and cardiovascular, neurological, respiratory, renal, hepatic and/or haematological dysfunction
• ERCP can lead to intra-abdominal or percutaneous bleeding, sepsis, fistulae and bile leakage
• severe obstructions of bile ducts can cause extreme infected bile reflux and sepsis

Question 25

What is the mortality if patients with acute cholangitis?

1 - 0.17 - 0.4%
2 - 1.7 - 4%
3 - 17 - 40%
4 - >50%

Answer 25

3 - 17 - 40%

• depends on accompanying medical problems and age. Early endoscopic drainage after stabilisation of the patient significantly improves the prognosis. Failure to respond to conservative therapy and underlying malignant aetiology are unfavourable factors.

Question 26

The following are all markers of poorer prognosis:

• hypoalbuminaemia with a prolonged prothrombin time (INR above 1.5)
• hyperbilirubinaemia
• high fever
• leukocytosis (high WCC)
• advanced age
• hypotension
• high CRP
• long period of antibiotic therapy