Acute cholangitis

Question 1

What is cholangitis?

Answer 1

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.

Question 2

What is the mortality rate of choloangitis?

Answer 2

It is an uncommon condition (1% of patients with gallstone disease) but is life-threatening with a mortality rate between 17 – 40%

Question 3

In which region of the abdomen is the gall bladder found?

Answer 3

right hypochondrium

Question 4

What is the name of the region where the pancreatic duct and common bile duct open into the duodenum?

Answer 4

Ampulla of Vater

Question 5

What is the name of the sphincter that surrounds the Ampulla of Vater?

Answer 5

Sphincter of Odi

Question 6

Who is acute cholangitis most common in?

Answer 6

. Cholangitis has an equal sex distribution, and the median age of presentation is 50-60 years old.

Question 7

What is the biliary tree?

Answer 7

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.

Question 8

What is the main function of the gallbladder?

Answer 8

The main function of the gallbladder is to store bile.

Question 9

What is the anatomy of the biliary tree?

Answer 9

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).

Question 10

Describe how bile duct obstruction fasciliates infection:

Answer 10

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.

Question 11

What are the three most common causative organisms of acute cholangitis?

Answer 11

1) Escherichia coli
2) Klebsiella species
3) Enterococcus species

Question 12

Give the three clinical features of Charcot’s triad:

Answer 12

1) right upper quadrant pain
2) fever
3) jaundice and raised bilirubin

Question 13

Other than the clinical features named in Charcot’s triad, give 4 other symptoms of acute cholangitis:

Answer 13

1) pruritis
2) pale stools
3) dark urine
4) nausea/ vomiting

Question 14

What is Reynold’s Pentad?

Answer 14

Charcot’s triad with hypotension, altered mental status (indicating systemic infection)

Question 15

What is Mirizzi syndrome?

Answer 15

stone in cystic duct causes compression on common bile duct, causing cholangitis

Question 16

What are the risk factors for developing cholangitis?

Answer 16

1. Gallstone disease (e.g. Mirizzi syndrome: where a stone-containing gallbladder extrinsically compresses the common bile duct; choledocholithiasis: gallstones in the common bile duct).
2. Iatrogenic biliary injury (e.g. during cholecystectomy or ERCP)
3. Tumours (pancreatic, cholangiocarcinoma, hepatic)
4. Sclerosing cholangitis (primary and secondary)
5. Biliary strictures (benign or malignant)
6. Parasitic infections (roundworm, liver fluke

Question 17

How can you clinically distinguish between cholecystitis and cholangitis?

Answer 17

cholecystitis will rarely present with jaundice

Question 18

Give 6 laboratory tests used to investigate cholangitis:

Answer 18

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)

Question 19

What LFT results would you expect in acute cholangitis? (3)

Answer 19

1) raised bilirubin
2) raised ALP
3) raised GGT

Question 20

What scan is used to identify gall stones?

Answer 20

transabdominal ultrasound

Question 21

What scan is used if transabdominal ultrasound is negative for gallstones but there is clinical suspicion of cholangitis?

Answer 21

CT abdomen

Question 22

What is the name of the scan that can produce a highly detailed 3D image of the biliary tree?

Answer 22

Magnetic resonance cholangiopancreatography (MRCP)

Question 23

What is the gold standard investigation AND intervention for acute cholangitis?

Answer 23

endoscopic retrograde cholangiopancreatography

Question 24

Describe the process of endoscopic retrograde cholangiopancreatography.

Answer 24

an endoscope is placed into the second part of the duodenum and cannulation of the ampulla to view to biliary tree

Question 25

Give two risks associated with ERCP:

Answer 25

1) acute pancreatitis
2) severe haemorrhage

Question 26

Give 4 immediate management techniques used to manage risk of sepsis in acute cholangitis:

Answer 26

1) nil by mouth
2) IV fluids
3) blood cultures
4) IV antibiotics

Question 27

Give 2 procedures that can be carried out during ERCP to reduce obstruction in the biliary tree:

Answer 27

1) stenting
2) balloon dilatation

Question 28

What is a sphincterotomy?

Answer 28

incising the sphincter of Odi to aid drainage of any common bile duct stones

Question 29

What treatment is considered for acute cholangitis if ERCP is deemed too dangerous?

Answer 29

percutaneous transhepatic cholangiography

Question 30

Describe the process of percutaneous transhepatic cholangiography:

Answer 30

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

Question 31

Give two surgical interventions used to treat acute cholangitis: (last resort)

Answer 31

1) cholecystectomy
2) laparoscopic choledochectomy with T tube placement

Question 32

What is a laparoscopic choledochotomy with T tube placement?

Answer 32

where the common bile duct is cut open and a drainage tube is inserted and left in place

Question 33

What are the differential diagnoses?

Answer 33

Hepatitis
Hepatic abscess
Pancreatitis
Mirizzi syndrome
Gilbert syndrome
Peptic ulcer disease

Question 34

What are 3 complications of cholangitis?

Answer 34

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