Acute cholangitis Flashcards
define acute cholangitis?
infection of the bile duct
outline the aetiology/ risk factors of acute cholangitis?
obstruction of gallbladder or bile duct due to stones
ERCP
Tumours ( pancreatic, cholangiocarcinoma)
bile duct structure or stenosis
parasitic infection ( ascariasis)
summarise the epidemiology of acute cholangitis?
- 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
what is charcot’s triad?
right upper quadrant pain- may refer to right shoulder
jaundice
fever with rigors
what is reynold’s pentad?
mental confusion
septic shock- hypotension
what are the presenting symptoms of acute cholangitis?
charcot’s symptoms
- right upper quadrants- may refer to right shoulder
- jaundice
- fever with rigors
Reynolds’ Pentad
- mental confusion
- septic shock- hypotension
- patients may also complain of pruritus
- stool colour is putty/ clay
what are the signs of acute cholangitis on physical examination?
fever
RUQ tenderness
Murphy’s sign positive
Mild hepatomegaly
Jaundice
Mental Status changes
Sepsis
Hypotension
Tachycardia
what are the investigations for acute cholangitis?
bloods
ERCP
Abdominal ultrasound- look for stones and dilation of the common bile duct
Contrast- enhanced- good for diagnosing cholangitis but not for detecting gall stones
MRCP- may be necessary to detect non-calcified stones-> when ultrasound
describe blood results for acute cholangitis?
○ FBC: High WCC, low plts
○ CRP/ESR: possibly raised
○ LFTs: typical pattern of obstructive jaundice (raised ALP + GGT)
○ U&Es: may be signs of renal dysfunction
○ Blood cultures: check for sepsis
○ Amylase: may be raised if the lower part of the common bile duct is involved
○ In severe cases low bicarbonate and met acidosis
PTT may be raised with sepsis
what are the possible complications of acute cholangitis?
- Liver abscesses
- Liver failure
- Bacteraemia
- Gram-negative sepsis
- Septic shock
- AKI
- Organ dysfunction
• Percutaneous or endoscopic drainage can lead to:
Intra-abdominal or percutaneous bleeding, sepsis, fistulae and bile leakage
summarise the prognosis for patients with acute cholangitis?
mortality between 17-40%
Outline a management plan for acute cholangitis?
• ABC
• IV antibiotics: given once blood cultures have been taken
○ Piperacillin + tazobactam
OR
○ Imipenem + cilastatin
OR
○ Cefepime + metronidazole
• Resuscitation: may be required if the patient is in septic shock – sepsis 6
• May need opioid analgesics
• Most patients respond to antibiotics but endoscopic biliary drainage is usually required to treat the underlying obstruction
○ ERCP
○ Lithotripsy (US shock waves) if bile duct stones are large or difficult to remove
Last line: choledectomy with T-tube places or cholecystectomy