Acute Cholangitis

Question 1

def

Answer 1

also known as ascending cholangitis
an infection of the biliary tree most commonly caused by obstruction
mild AC - there is biliary obstruction with inflammation
severe AC - with sepsis, hypotension, multi-organ failure, changes in mental state

Question 2

aetiology

Answer 2

most commonly:
cholelithiasis (formation of gallstones) leading to choledocholithiasis (gallstones in the bile duct) and biliary obstruction
commonly:
iatrogenic biliary duct injury during cholecystectomy (removal of gall bladder) can lead to obstruction
commonly:
chronic pancreatitis (acute less common)
commonly:
sclerosing cholangitis
uncommonly:
-primary biliary tumours
-primary gallbladder cancer
-pancreatic cancer

Question 3

epi

Answer 3

uncommon - 1% of cholelithiasis (formation of gallstones)
male=females
50-60yrs

Question 4

what are the risk factors for AC

Answer 4

age >50yrs
cholelithiasis
sclerosing cholangitis (primary/secondary)

Question 5

history & examination

Answer 5

presence of risk factors
RUQ pain (diffuse pain, murphys sign negative) & tenderness
jaundice
fever

in severe AC

• hypotension
• mental status changes

Question 6

what is murphys sign

Answer 6

hypersensitivity to deep palpation in the subcostal area when a patient with gallbladder disease inspires deeply
in inspiration the abdominal contents move down as the diaphragm moves down

Question 7

what is murphys sign positive in

Answer 7

cholecsystitis

Question 8

what is murphys sign negative in

Answer 8

choledocholithiasis
pyelonephritis
AC

Question 9

investigations

Answer 9

1 bloods
-FBC (raised WCC)
-serum urea & creatinine (raised in severe cases)
-serum LFTs (hyperbilirubinaemia, raised serum transaminases, raised alk phos)
-CRP (raised)
2 blood cultures
-usually gram negative bacteria
3 Abdominal USS
-dilated bile duct
-common bile duct stones

Question 10

management

Answer 10

FIRST LINE TREATMENT
1 IV broad-spectrum antibiotics until culture results obtained
primary options
-piperacillin/tazobactam
-imipenem/cilastatin
-cefepime & metronidazole
secondary options
-ciprofloxacin/levofloxacin & metronidazole
2 biliary decompression may be required
3 for large bile duct stones, lithotripsy (USS shock waves break down stone)
4 opoids for pain management (morphine)
SECOND LINE TREATMENT
1 surgical biliary decompression if sufficient biliary decompression is not achieved by non-operative means
2 IV antibiotics (see above)
3 opoids for pain management (morphine)

Question 11

complications

Answer 11

moderate chance of acute pancreatitis (bile duct stones can obstruct pancreatic duct)
low chance of inadequate biliary drainage following endoscopy/surgery
low chance of hepatic abscess (more common with sclerosing cholangitis)

Question 12

prognosis

Answer 12

if adequate biliary drainage is obtained quickly, majority of patients recover rapidly
poorer prognosis with hyperbilirubinaemia, leukocytosis, fever, elderly

Question 13

what poo might be seen in ascending cholangitis

Answer 13

clay-coloured poop

Question 14

what are the diagnostic criteria for ascending cholangitis

Answer 14

A systemic inflammation
1 fever
2 raised WCC or CRP
B cholestasis
1 jaundice
2 LFTs indicating obstruction in biliary tree
C imaging
1 biliary dilation
2 evidence of cause (stricture or stone)

one item from ABC required for diagnosis