Acute cholangitis

Question 1

What is acute cholangitis?

Answer 1

Infection of the biliary duct as a result of biliary obstruction; characterised by Charcot’s triad - RUQ pain, jaundice, fever (or Reynold’s Pendant) (mental status changes + sepsis)

Question 2

What are the risk factors for acute cholangitis?

Answer 2

Anything that blocks the bile duct so bile cannot flow through 
- Gall stone causing obstruction in biliary tree (choledocholithiasis) 
- ERCP 
- Tumours (pancreatic, cholangiocarcinoma etc.) 
- Bile duct strictures or stenosis 
- Parasitic infection (ascariasis) 
*Bacteria includes - E.coli, Klebsiella, enterococcus

Question 3

What are the presenting symptoms of acute cholangitis?

Answer 3

1. Most patients present with Charcot’s Triad of symptoms:
   - RUQ Pain – may refer to right shoulder
   - Jaundice
   - Fever with rigors
2. This list of symptoms has been extended to include the following two symptoms, forming the Reynolds’ Pentad:
   - Mental confusion
   - Septic shock - hypotension
   - Patients may also complain of pruritus (itching)

Question 4

Summarise the epidemiology of acute cholangitis

Answer 4

9% of patients admitted to hospital with gallstone disease will have acute cholangitis
Equal in males and females
Median age of presentation: 50-60 yrs
Racial distribution follows that of gallstone disease - fair-skinned people

Question 5

What signs of acute cholangitis can be found on physical examination?

Answer 5

• Fever
• RUQ tenderness
• Murphy’s sign positive
• Mild hepatomegaly
• Jaundice
• Mental status changes
• Sepsis
• Hypotension
• Tachycardia
• Peritonitis (uncommon - check for alternative diagnosis)
• Charcot’s triad or Reynold’s pendant (with confusion/hypotension) 

Question 6

What investigations are used to diagnose/ monitor acute cholangitis?

Answer 6

1. Ultrasound Scan → first-line in suspected cases to look for common bile duct dilation and bile duct stones
2. Increased WBC & CRP
3. LFTs → Hyperbilirubinaemia, raised serum Transaminases (ALT) & Alkaline Phosphatase (ALP) (abnormal LFTs suggests cholangitis rather than cholecystitis)
4. Urea & Creatinine → Raised
5. Blood Cultures → check for sepsis & establish causative organism
6. ABG → Order on suspicion of sepsis = low bicarbonate, metabolic acidosis, raided lactate (severe)
7. ERCP → best first intervention, helps observe bile duct stone
   - ERCP may cause pancreatitis
   - ERCP = remove a gallstone from common bile duct. Cholecystectomy = remove gallbladder.
   - (ERCP is imaging + therapeutic. MRCP is just imaging)
8. The most accurate imaging modality for ascending cholangitis is an MRCP, which can determine the cause of the biliary tree blockage; such causes include gallstones and strictures.

Question 7

How is acute cholangitis managed?

Answer 7

1. ABC
2. 1st line: Broad-spectrum antibiotics: given once blood cultures have been taken (select drugs that are effective against anaerobes and Gram-negative organisms: e.g. cefuroxime + metronidazole)
3. Resuscitation: may be required if the patient is in septic shock – sepsis 6
4. 2nd line: ERCP Drainage after 24-48 hours to relieve any obstruction (blocked common bile duct is drained - will be dilated)
5. give bolus IV fluids + Analgesia
6. Elective Cholecystectomy when patient is well to prevent further episodes

Question 8

What complications may arise from acute cholangitis?

Answer 8

• Liver abscesses
• Liver failure
• Bacteraemia
• Gram-negative sepsis
• Septic shock
• AKI
• Organ dysfunction
• Percutaneous or endoscopic drainage can lead to:
  *Intra-abdominal or percutaneous bleeding, sepsis, fistulae and bile leakage

Question 9

Summarise the prognosis for patients with acute cholangitis

Answer 9

Mortality between 17-40%