Acute Cholangitis

Question 1

Definition

Answer 1

Infection of the bile duct

Question 2

Aetiology/Risk factors

Answer 2

· There are several causes:

o Obstruction of the gallbladder or bile duct due to stones
o ERCP
o Tumours (e.g. pancreatic, cholangiocarcinoma)
o Bile duct stricture or stenosis
o Parasitic infection (e.g. ascariasis)

Question 3

Epidemiology

Answer 3

· 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 4

Presenting symptoms

Answer 4

· Most patents present with Charcot’s Triad of symptoms:
o RUQ Pain
o Jaundice
o Fever with rigors

· This list of symptoms has been extended to include the following two symptoms, forming the Reynolds’ Pentad:
o Mental confusion
o Septic shock

· Patients may also complain of pruritus

Question 5

Signs on physical examination

Answer 5

· Fever
· RUQ tenderness
· Mild hepatomegaly
· Jaundice
· Mental status changes
· Sepsis
· Hypotension
· Tachycardia
· Peritonitis (uncommon - check for alternative diagnosis)

Question 6

Investigation (bloods)

Answer 6

o FBC: High WCC
o CRP/ESR: possibly raised
o LFTs: typical pattern of obstructive jaundice (raised ALP + GGT)
o U&Es: may be signs of renal dysfunction
o Blood cultures: check for sepsis
o Amylase: may be raised if the lower part of the common bile duct is involved

Question 7

Investigation (imaging)

Answer 7

o X-ray KUB: look for stones
o Abdominal ultrasound: look for stones and dilation of the common bile duct
o Contrast-enhanced CT/MRI: good for diagnosing cholangitis
o MRCP: may be necessary to detect non-calcified stones

Question 8

Management plan

Answer 8

· Resuscitation: may be required if the patient is in septic shock

· 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)

· Most patients respond to antibiotics but endoscopic biliary drainage is usually required to treat the underlying obstruction

Question 9

Management for each stage

Answer 9

· Management depends on severity:

o Stage 1 (Mild)
· Antimicrobial therapy
· Percutaneous, endoscopic or operative intervention for non-responders (depending on aetiology)

o Stage 2 (Moderate)
· Early percutaneous or endoscopic drainage
· Endoscopic biliary drainage is recommended

o Stage 3 (Severe)
· NOTE: severe cholangitis counts as including shock, conscious disturbance, acute lung injury, AKI, hepatic injury or DIC
· Treatment of organ failure with ventilatory support, vasopressors etc.
· Urgent percutaneous or endoscopic drainage
· Definitive treatment required once the clinical picture improves

Question 10

Possible complications

Answer 10

· Liver abscesses
· Liver failure
· Bacteraemia
· Gram-negative sepsis
· Septic shock
· AKI
· Organ dysfunction

· Percutaneous or endoscopic drainage can lead to:
o Intra-abdominal or percutaneous bleeding, sepsis, fistulae and bile leakage

Question 11

Prognosis

Answer 11

Mortality between 17-40%