Acute cholangitis

Question 1

Acute cholangitis (aka ascending cholangitis)

What is it?

Answer 1

a condition characterised by inflammation of the biliary tract, which results from stasis and infection from bacteria generally coming from the intestine

Question 2

Acute cholangitis (aka ascending cholangitis)

Having what procedure done increases a pt risk of acute cholangitis?

Answer 2

permanent biliary stent

Question 3

Acute cholangitis (aka ascending cholangitis)

What are the top 3 most frequent causes of INtrinsic bile duct obstruction and consequent infection?

Answer 3

1. biliary stones
2. benign biliary strictures
3. malignant biliary strictures

Question 4

Acute cholangitis (aka ascending cholangitis)

What are 4 frequent causes of EXtrinsic bile duct obstruction and consequent infection?

Answer 4

• malignancy
• inflammation (acute pancreatitis)
• Mirizzi syndrome
• parasitic infections of liver

Question 5

Acute cholangitis (aka ascending cholangitis)

Name the top iatrogenic cause of cholangitis.

Answer 5

ERCP

Question 6

Acute cholangitis (aka ascending cholangitis)

How does it present?

Answer 6

Charcot’s triad:
- fever
- jaundice
- abdo pain

Question 7

Acute cholangitis (aka ascending cholangitis)

Along with Charcot’s triad, what other presentation may a pt with pyogenic cholangitis present with?

Answer 7

• hypotension
• change in mental status

Question 8

Acute cholangitis (aka ascending cholangitis)

How is it diagnosed?

Answer 8

fever
OR
lab evidence of systemic inflammation

AND
- Cholestasis: with bilirubin >= 2 mg/dL or abnormal LFTs > 1.5 ULN
- Imaging suggestive of biliary dilation or aetiology (stone, stent, stenosis)

Ascending cholangitis is defined as moderate instead if two of the following are present: abnormal WBC count, fever > 39 °C, age >= 75, bilirubin >= 5 mg/dL or hypoalbuminemia.

Question 9

Acute cholangitis (aka ascending cholangitis)

What investigstions do we do?

Answer 9

• Full blood count (FBC)
• LFTs
• Blood cultures
• Bile or stent cultures (if stent removed at ERCP)
• Imaging

Question 10

Acute cholangitis (aka ascending cholangitis)

How might the full blood count come back?

Answer 10

elevated WBC count with predominance of neutrophils

Question 11

Acute cholangitis (aka ascending cholangitis)

How might the LFTs come back?

Answer 11

cholestatic pattern (elevated ALP, GGT and conjugated bilirubin)

Question 12

Acute cholangitis (aka ascending cholangitis)

Explain the progression of imaging techniques and why we use each one.

Answer 12

• Abdominal US: to look for bile duct dilatation and/or stones
• Abdominal CT: if US is normal, to look for bile duct dilatation and/or strictures
• MRCP: if US or CT are normal
• ERCP: for those who cannot undergo MRCP but with high suspicion of biliary obstruction e.g. conjugated hyperbilirubinemia. Can be therapeutic.
• EUS: for those who cannot undergo MRCP, if liver tests are normal or patient is at high risk of complications from ERCP (e.g. pregnancy). Can be therapeutic.

Question 13

Acute cholangitis (aka ascending cholangitis)

How do we manage it? (prescribing)

Answer 13

1. IV hydration
2. analgesia
3. ABx therapy

Question 14

Acute cholangitis (aka ascending cholangitis)

How do we manage it? (non-prescribing)

Answer 14

1. monitor for sepsis/organ failure
2. drainage (ERCP)
3. delayed elective cholecystectomy for pt w/ gallstone-related cholangitis