Acute cholangitis Flashcards
What is cholangitis?
Acute cholangitis (a.k.a. ascending cholangitis) is an infection of the biliary tree caused by a combination of both biliary outflow obstruction and biliary infection.
What is the mortality rate of choloangitis?
It is an uncommon condition (1% of patients with gallstone disease) but is life-threatening with a mortality rate between 17 – 40%
In which region of the abdomen is the gall bladder found?
right hypochondrium
What is the name of the region where the pancreatic duct and common bile duct open into the duodenum?
Ampulla of Vater
What is the name of the sphincter that surrounds the Ampulla of Vater?
Sphincter of Odi
Who is acute cholangitis most common in?
. Cholangitis has an equal sex distribution, and the median age of presentation is 50-60 years old.
What is the biliary tree?
The biliary tree is the system of ducts that transports bile (synthesised by hepatocytes) to the gallbladder for storage and then on to the duodenum.
What is the main function of the gallbladder?
The main function of the gallbladder is to store bile.
What is the anatomy of the biliary tree?
The ducts begin in the liver parenchyma until the right and left hepatic ducts are formed (which drain bile from the left and right lobes of the liver). These two ducts then anastomose to form the common hepatic duct.
The duct which arises from the gallbladder is known as the cystic duct. The cystic duct joins the hepatic duct forming the common bile duct (CBD) which then enters the pancreas.
In the pancreatic head, the common bile duct and the pancreatic duct join to form the ampulla of Vater, which empties into the descending part of the duodenum via the major duodenal papilla (controlled by the sphincter of Oddi, a muscular valve).
Describe how bile duct obstruction fasciliates infection:
when the bile duct becomes obstructed, movement of bile stops, forming biliary sludge which acts as an ideal growth medium for bacteria
The pressure within the biliary system also increases as a result of obstruction increasing the risk of bacterial translocation into the bloodstream resulting in biliary sepsis.
What are the three most common causative organisms of acute cholangitis?
1) Escherichia coli
2) Klebsiella species
3) Enterococcus species
Give the three clinical features of Charcot’s triad:
1) right upper quadrant pain
2) fever
3) jaundice and raised bilirubin
Other than the clinical features named in Charcot’s triad, give 4 other symptoms of acute cholangitis:
1) pruritis
2) pale stools
3) dark urine
4) nausea/ vomiting
What is Reynold’s Pentad?
Charcot’s triad with hypotension, altered mental status (indicating systemic infection)
What is Mirizzi syndrome?
stone in cystic duct causes compression on common bile duct, causing cholangitis
What are the risk factors for developing cholangitis?
- Gallstone disease (e.g. Mirizzi syndrome: where a stone-containing gallbladder extrinsically compresses the common bile duct; choledocholithiasis: gallstones in the common bile duct).
- Iatrogenic biliary injury (e.g. during cholecystectomy or ERCP)
- Tumours (pancreatic, cholangiocarcinoma, hepatic)
- Sclerosing cholangitis (primary and secondary)
- Biliary strictures (benign or malignant)
- Parasitic infections (roundworm, liver fluke
How can you clinically distinguish between cholecystitis and cholangitis?
cholecystitis will rarely present with jaundice
Give 6 laboratory tests used to investigate cholangitis:
1) FBC (raised WCC = infection)
2) U&Es (raised urea and creatinine = organ dysfunction)
3) LFTs (deranged)
4) CRP (raised due to inflammatory process)
5) blood cultures (ideally before antibiotic therapy is commenced)
6) coagulation profile (often deranged in obstructive biliary disease)
What LFT results would you expect in acute cholangitis? (3)
1) raised bilirubin
2) raised ALP
3) raised GGT
What scan is used to identify gall stones?
transabdominal ultrasound
What scan is used if transabdominal ultrasound is negative for gallstones but there is clinical suspicion of cholangitis?
CT abdomen
What is the name of the scan that can produce a highly detailed 3D image of the biliary tree?
Magnetic resonance cholangiopancreatography (MRCP)
What is the gold standard investigation AND intervention for acute cholangitis?
endoscopic retrograde cholangiopancreatography
Describe the process of endoscopic retrograde cholangiopancreatography.
an endoscope is placed into the second part of the duodenum and cannulation of the ampulla to view to biliary tree
Give two risks associated with ERCP:
1) acute pancreatitis
2) severe haemorrhage
Give 4 immediate management techniques used to manage risk of sepsis in acute cholangitis:
1) nil by mouth
2) IV fluids
3) blood cultures
4) IV antibiotics
Give 2 procedures that can be carried out during ERCP to reduce obstruction in the biliary tree:
1) stenting
2) balloon dilatation
What is a sphincterotomy?
incising the sphincter of Odi to aid drainage of any common bile duct stones
What treatment is considered for acute cholangitis if ERCP is deemed too dangerous?
percutaneous transhepatic cholangiography
Describe the process of percutaneous transhepatic cholangiography:
a needle is passed through the skin into the bile ducts and contrast material is injected so that a drain can be inserted and fixed to the skin
Give two surgical interventions used to treat acute cholangitis: (last resort)
1) cholecystectomy
2) laparoscopic choledochectomy with T tube placement
What is a laparoscopic choledochotomy with T tube placement?
where the common bile duct is cut open and a drainage tube is inserted and left in place
What are the differential diagnoses?
Hepatitis
Hepatic abscess
Pancreatitis
Mirizzi syndrome
Gilbert syndrome
Peptic ulcer disease
What are 3 complications of cholangitis?
Acute pancreatitis: stones in the distal common bile duct causing cholangitis can also lead to blockage of the pancreatic duct
Inadequate biliary drainage following endoscopy, radiology or surgery
Hepatic abscess formation
