Acute Cholangitis

Question 1

What is acute cholangitis?

Answer 1

infection of the bile duct.

Question 2

List 5 causes of acute cholangitis

Answer 2

Obstruction of 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

Describe the epidemiology of acute cholangitis

Answer 3

M = F
50-60 yrs
Fair-skinned people

Question 4

List symptoms of of acute cholangitis

Answer 4

Charcots triad:
RUQ Pain 
Jaundice  
Fever with rigors 
Reynolds' Pentad: 
Confusion 
Septic shock 
Pts may also complain of pruritus

Question 5

List 9 signs of acute cholangitis

Answer 5

Fever  
RUQ tenderness 
Mild hepatomegaly 
Jaundice  
Mental status changes 
Sepsis 
Hypotension 
Tachycardia 
Peritonitis (uncommon: consider other causes)

Question 6

List the bloods taken in acute cholangitis

Answer 6

FBC: High WCC
High CRP/ ESR
LFTs: pattern of obstructive jaundice (High BR, ALP + GGT)
U+Es: may be signs of renal dysfunction
Blood cultures: check for sepsis
Amylase: raised if lower part of CBD is involved

Question 7

What imaging is performed in suspected acute cholangitis?

Answer 7

Abdominal USS: identify stones + dilation of CBD
MRCP
ERCP: diagnostic + therapeutic (GS)
Contrast-enhanced CT/ MRI

Question 8

Describe treatment of acute cholangitis

Answer 8

Resus: if pt in septic shock
B-S abx: once blood cultures have been taken (drugs effective against anaerobes + Gram -ve organisms: e.g. Ciprofloxacin + metronidazole)
Endoscopic biliary drainage to treat underlying obstruction

Question 9

List 7 complications of acute cholangitis

Answer 9

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

Question 10

What is the prognosis for patients with acute cholangitis?

Answer 10

Mortality between 17-40%

Question 11

Describe the staging and respective treatment of acute cholangitis

Answer 11

Stage 1 (Mild)
Antimicrobials
Percutaneous, endoscopic or operative intervention for non-responders
Stage 2 (Moderate)
Early percutaneous or endoscopic drainage
Stage 3 (Severe)
inc. shock, LOC, acute lung injury, AKI, hepatic injury or DIC
Tx of organ failure with ventilatory support, vasopressors etc.
Urgent percutaneous/ endoscopic drainage
Definitive tx required once clinical picture improves

Question 12

List 4 complications of percutaneous or endoscopic drainage

Answer 12

Intra-abdominal or percutaneous bleeding
Sepsis
Fistulae
Bile leakage