Acute cholangitis

Question 1

Aetiology of acute cholangitis

Answer 1

Infection + inflammation of the bile ducts

Surgical emergency - high mortality due to sepsis

Question 2

Pathophysiology of Acute cholangitis

Answer 2

2 main causes:

• obstruction of the bile ducts stopping bile flow (i.e. gallstones in the common bile duct)
• infection introduced during an ERCP procedure

most common organisms:

1. escherichia coli
2. klebisella species
3. enterococcus species

Question 3

Clinical presentation of acute cholangitis

Answer 3

Charcot’s triad

• right upper quadrant pain
• fever
• jaundice (raised bilirubin)

Question 4

Investigations for diagnosis of acute cholangitis

Answer 4

imaging:

• abdominal ultrasound scan
• CT scan
• magnetic resonance cholangio-pancreatography (MRCP)
• endoscopic ultrasound

Question 5

Treatment for acute cholangitis?

Answer 5

Acute management of sepsis and acute abdomen:

• nil by mouth
• IV fluids
• Blood cultures
• IV antibiotics
• Involvement of seniors and potentially HDU or ICU

Endoscopic retrograde cholangio-pancreatography (ERCP)

Percutaneous transhepatic cholangiogram (PTC)

Question 6

Explain how ERCP can treat acute cholangitis?

Answer 6

→ required to remove stones blocking the bile duct

• involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (thesphincter of Oddi)

This gives the operator access to the biliary system. A number of procedures can be performed during an ERCP:

• Cholangio-pancreatography: retrograde injection of contrast into the duct through the sphincter of Oddi and x-ray images to visualise biliary system
• Sphincterotomy: making a cut in the sphincter to dilate it and allow stone removal
• Stone removal: a basket can be inserted and pulled through thecommon bile ductto remove stones
• Balloon dilatation: a balloon can be inserted and inflated to treat strictures
• Biliary stenting: a stent can be inserted to maintain a patent bile duct (for strictures or tumours)
• Biopsy: a small biopsy can be taken to diagnose obstructing lesions

Question 7

Explain how percutaneous transheptic cholangiogram (PTC) can treat acute cholangitis?

Answer 7

involves radiologically guided insertion of a drain through the skin and liver, into the bile ducts. The drain relieves the immediate obstruction. A stent can be inserted to give longer-lasting relief of obstruction. This is an option for patients that are less suitable for ERCP, or where ERCP has failed.