Acute Cholangitis

Question 1

Define Ascending Cholangitis:

Answer 1

Infection of the Biliary Tract

Question 2

What is the most common cause of Ascending Cholangitis?

Answer 2

Obstruction of the Common Bile Duct by a Gallstone

Question 3

List 4 less common causes of Ascending Cholangitis:

Answer 3

ERCP (Endoscopic Retrograde Cholangiopancreatography)

Tumours (Pancreatic, Cholangiocarcinoma)

Bile duct Stricture/Stenosis

Parasitic Infection (e.g. ascariasis)

Question 4

Epidemiology of Acute Cholangitis:

Sex Distribution

Median Age

Racial Distribution

% of Pts admitted with Gallstone Disease

Answer 4

Equal in Males and Females

50-60 yrs

Follows distribution of gallstone disease - fair-skinned people

9% of patients admitted to hospital with gallstone disease will have acute cholangitis

Question 5

How do Patients with Acute Cholangitis present?

Answer 5

Reynolds’ Pentad:

Charcot’s Triad:

• RUQ Pain
• Jaundice
• Pyrexia

+

• Mental Confusion
• Septic Shock/Hypotension

(maybe Pruritus)

Question 6

List what you may find on examination of Acute Cholangitis:

Answer 6

Fever

Jaundice

RUQ tenderness

Mild Hepatomegaly

Signs of Sepsis - Hypotension, Tachycardia

Question 7

What are the pathogens commonly involved in Acute Cholangitis?

Answer 7

Escherechia coli (25%-50%)

Klebsiella species (15%-20%)

Enterococcus species (10%-20%)

Enterobacter species (5%-10%)

Question 8

Explain why a stone in the Bile duct causes Ascending Cholangitis:

Answer 8

A stone blocks the flow of bile down the duct and out of the Ampulla of Vater

Cholestasis allows gut bacteria to enter the duct and cause infection

The bacteria can enter the blood as the increased intraductal pressure causes the tight junctions between cholangiocytes to widen - sepsis

Question 9

What is it technically called when there is pus extruding from the ampulla of vater?

Answer 9

Acute Suppurative Cholangitis (ASC)

Question 10

What bloods should be requested in Acute Cholangitis?

What would you expect to see?

Answer 10

Blood Culture - sepsis

FBC - High WCC

ESR/CRP - raised

LFTs - pattern of obstructive jaundice (raised ALP + GGT)

U&Es - may be derranged

Prothrombin + INR - possible coagulopathy

Question 11

What are the appropriate imaging studies for Acute Cholangitis?

Answer 11

X-ray KUB: look for stones

Abdominal ultrasound: look for stones and dilation of the common bile duct (or endoscopic ultrasound EUS)

Contrast-enhanced CT: good for diagnosing cholangitis

MRCP: may be necessary to detect non-calcified stones (magnetic resonance cholangiopancreatography)

[MRCP and EUS are most sensitive]

Question 12

How would you manage a case of Acute Cholangitis:

Answer 12

Resuscitation - if sepsis

Broad-Spectrum Antibiotics - covering Gram -ve and Anaerobes: Ceftriaxone + Metronidazole

ERCP w/ biliary drainage of obstruction (if no response to antibiotics)

Question 13

List 8 potential complications of Acute Cholangitis:

Answer 13

• 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

Question 14

What is the mortality of Acute Cholangitis?

Answer 14

<10-40%

<10% after biliary drainage

Pre-ERCP was >50% in severe cases

Emergency Surgery carries mortality of about 30%