Acute Cholangitis Flashcards
Define Acute Cholangitis?
Infection of the bile duct
What are some of the causes of Acute Cholangitis?
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)
What is 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 are the presenting symptoms of Acute Cholangitis ?
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
What is Charcot’s Triad?
RUQ Pain
Jaundice
Fever with rigors
What is Reynolds’ Pentad?
Mental Confusion
Septic Shock
What are the signs of Acute Cholangitis on physical examination?
Fever RUQ tenderness Mild hepatomegaly Jaundice Mental Status Changes Sepsis Hypotension Tachycardia Peritonitis (uncommon - check for alternative diagnosis)
What bloods would you do for Acute Cholangitis?
FBC CRP/ESR LFTs U&Es Blood Cultures Amylase
What would you specifically look for on a FBC for Acute Cholangitis?
High WCC
What would you see for CRP/ESR for Acute Cholangitis?
Possibly raised
What would you see on LFTs for Acute Cholangitis?
Typical pattern of obstructive jaundice (raised ALP + GGT)
What might you see on U&Es for Acute Cholangitis?
May be signs of renal dysfunction
Why do we do Blood Cultures for Acute Cholangitis?
Check for sepsis
Why do we do Amylase for Acute Cholangitis?
May be raised if the lower part of the common bile duct is involved
What imaging do you do for Acute Cholangitis?
X-Ray
Abdominal US
Contrast-enhanced CT/MRI
MRCP
Why do we do an X-Ray KUB for Acute Cholangitis?
Look for stones
Why do we do an Abdominal US for Acute Cholangitis?
Look for stones and dilation of the common bile duct
Why do we do CT/MRI for Acute Cholangitis?
Good for diagnosing cholangitis
Why do we do MRCP for Acute Cholangitis?
May be necessary to detect non-calcified stones
When is management of Acute Cholangitis dependent on?
Severity
What is Stage 1 of the management plan for Acute Cholangitis (treatment for Mild Acute Cholangitis)?
Antimicrobial Therapy
Percutaneous, endoscopic or operative intervention for non-responders (depending on aetiology)
What is Stage 2 (for moderate Acute Cholangitis) of the management plan for Acute Cholangitis?
Early percutaneous or endoscopic drainage
Endoscopic Biliary Drainage is recommended
What is Stage 3 (for Severe Acute Cholangitis) of the management plan for Acute Cholangitis?
Treatment of organ failure with ventillary support, vasopressors etc.
Urgent percutaneous or endoscopic drainage
Definitive treatment required once the clinical picture improves
What counts as Severe Cholangitis?
Including shock, consious disturbance, acute lung injury, AKI, hepatic injury or DIC
When do we do Resuscitation for Acute Cholangitis?
May be required if the patient is in septic shock
When are Broad-spectrum antibiotics given in Acute Cholangitis management?
Once blood cultures have been taken
How do we select which Broad-Spectrum Antibiotics to choose for Acute Cholangitis?
Select drugs that are effective against anaerobes and Gram-negative organisms: e.g. Cerufoxime + metronidazole
How do patients with Acute Cholangitis react to Antibiotics?
Most patients respond to antibiotics but endoscopic biliary drainage is usually required to treat the underlying obstruction
What are the possible complications of Acute Cholangitis?
Liver Abscesses Liver Failure Bacteraemia Gram-negative sepsis Septic-Shock AKI Organ dysfunction
What are some of the complications of Percutaneous and Endoscopic drainage?
It can lead to:
- Intra-abdominal or percutaneous bleeding
- Sepsis
- Fistulae
- Bile leakage
What is the prognosis for paients with Acute Cholangitis?
Moratility between 17-40%
