Acute Cholangitis

Question 1

What are the causes of cholangitis worldwide?

Answer 1

Majority of the world, secondary choledocholithiasis; Southeast Asia, oriental cholangiohepatitis (primary choledocholithiasis)

Question 2

What mechanisms maintain normal sterility of the biliary tract?

Answer 2

a) intact sphincter of Oddi which prevents reflux of duodenal contents b) unimpeded efflux of bile from CBD c)immunoglobulin A in bile c)bacteriostatic properties of bile salts

Question 3

What are the common bacteria cultured from patients with acute cholangitis and how are these different from those cultured in elderly patients and those who have undergone biliary instrumentation?

Answer 3

E. coli, Klebsiella, Enterobacter, Enterococcus (common); elderly-Bacteriodes, Clostridium (in addition to the the above listed)

Question 4

What is charcot’s triad?

Answer 4

fever, jaundice, RUQ abdominal pain

Question 5

What is Reynold’s pentad?

Answer 5

Charcot’s triad + mental status change and hypotension

Question 6

What are the most common elevated liver function tests in cholangitis?

Answer 6

Alk Phos, GGT, and CONJUGATED Bilirubin

Question 7

What is the best initial test if you are concerned for cholangitis?

Answer 7

Ultrasound

Question 8

In a patient with cholangitis, and ERCP is not available or unsuccessful, what is the next course of action?

Answer 8

percutaneous transhepatic cholangiography (PTC) if bile ducts are dilated, then CBD exploration

Question 9

What should be done during ERCP but prior to injection of contrast in patients with occlusive cholangitis and why?

Answer 9

aspiration of bile to decompress CBD; if not done, this can induce bacteremia, sepsis, and rapid decompensation

Question 10

What procedures can be performed endoscopically for patients who have contradindication to sphincterotomy but also have cholangitis?

Answer 10

Nasobiliary drain or Internal Biliary stent without sphincterotomy

Question 11

What are the indications for percutaneous transhepatic drainage?

Answer 11

Patients who fail ERCP, pts with difficult to access biliary tree (e.g. hepaticojejunostomy), proximal biliary obstruction (e.g. hilar cholangiocarcinoma), large periampullary duodenal diverticula, intrahepatic biliary obstruction from hepatolithiasis