Acute Cholangitis

Question 1

Define Acute Cholangitis?

Answer 1

Infection of the bile duct

Question 2

What are some of the causes of Acute Cholangitis?

Answer 2

Obstruction of the gallbladder or bile duct due to stones
ERCP
Tumours (e.g. Pancreatic, cholangiocarcinoma)
Bile duct stricture or stenosis
Parasitic Infection (e.g. Ascariasis)

Question 3

What is the epidemiology of Acute Cholangitis?

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

What are the presenting symptoms of Acute Cholangitis ?

Answer 4

Most patients present with Charcot’s Triad of symptoms
This list of symptoms has been extended to include the following two symptoms, following the Reynolds’ Pentad
Patients may also complain of Pruritis

Question 5

What is Charcot’s Triad?

Answer 5

RUQ Pain
Jaundice
Fever with rigors

Question 6

What is Reynolds’ Pentad?

Answer 6

Mental Confusion

Septic Shock

Question 7

What are the signs of Acute Cholangitis on physical examination?

Answer 7

Fever 
RUQ tenderness 
Mild hepatomegaly
Jaundice 
Mental Status Changes 
Sepsis 
Hypotension
Tachycardia 
Peritonitis (uncommon - check for alternative diagnosis)

Question 8

What bloods would you do for Acute Cholangitis?

Answer 8

FBC 
CRP/ESR
LFTs
U&Es
Blood Cultures 
Amylase

Question 9

What would you specifically look for on a FBC for Acute Cholangitis?

Answer 9

High WCC

Question 10

What would you see for CRP/ESR for Acute Cholangitis?

Answer 10

Possibly raised

Question 11

What would you see on LFTs for Acute Cholangitis?

Answer 11

Typical pattern of obstructive jaundice (raised ALP + GGT)

Question 12

What might you see on U&Es for Acute Cholangitis?

Answer 12

May be signs of renal dysfunction

Question 13

Why do we do Blood Cultures for Acute Cholangitis?

Answer 13

Check for sepsis

Question 14

Why do we do Amylase for Acute Cholangitis?

Answer 14

May be raised if the lower part of the common bile duct is involved

Question 15

What imaging do you do for Acute Cholangitis?

Answer 15

X-Ray
Abdominal US
Contrast-enhanced CT/MRI
MRCP

Question 16

Why do we do an X-Ray KUB for Acute Cholangitis?

Answer 16

Look for stones

Question 17

Why do we do an Abdominal US for Acute Cholangitis?

Answer 17

Look for stones and dilation of the common bile duct

Question 18

Why do we do CT/MRI for Acute Cholangitis?

Answer 18

Good for diagnosing cholangitis

Question 19

Why do we do MRCP for Acute Cholangitis?

Answer 19

May be necessary to detect non-calcified stones

Question 20

When is management of Acute Cholangitis dependent on?

Answer 20

Severity

Question 21

What is Stage 1 of the management plan for Acute Cholangitis (treatment for Mild Acute Cholangitis)?

Answer 21

Antimicrobial Therapy

Percutaneous, endoscopic or operative intervention for non-responders (depending on aetiology)

Question 22

What is Stage 2 (for moderate Acute Cholangitis) of the management plan for Acute Cholangitis?

Answer 22

Early percutaneous or endoscopic drainage

Endoscopic Biliary Drainage is recommended

Question 23

What is Stage 3 (for Severe Acute Cholangitis) of the management plan for Acute Cholangitis?

Answer 23

Treatment of organ failure with ventillary support, vasopressors etc.
Urgent percutaneous or endoscopic drainage
Definitive treatment required once the clinical picture improves

Question 24

What counts as Severe Cholangitis?

Answer 24

Including shock, consious disturbance, acute lung injury, AKI, hepatic injury or DIC

Question 25

When do we do Resuscitation for Acute Cholangitis?

Answer 25

May be required if the patient is in septic shock

Question 26

When are Broad-spectrum antibiotics given in Acute Cholangitis management?

Answer 26

Once blood cultures have been taken

Question 27

How do we select which Broad-Spectrum Antibiotics to choose for Acute Cholangitis?

Answer 27

Select drugs that are effective against anaerobes and Gram-negative organisms: e.g. Cerufoxime + metronidazole

Question 28

How do patients with Acute Cholangitis react to Antibiotics?

Answer 28

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

Question 29

What are the possible complications of Acute Cholangitis?

Answer 29

``` Liver Abscesses Liver Failure Bacteraemia Gram-negative sepsis Septic-Shock AKI Organ dysfunction ```

Question 30

What are some of the complications of Percutaneous and Endoscopic drainage?

Answer 30

It can lead to: - Intra-abdominal or percutaneous bleeding - Sepsis - Fistulae - Bile leakage

Question 31

What is the prognosis for paients with Acute Cholangitis?

Answer 31

Moratility between 17-40%