Acute cholangitis

Question 1

Define acute cholangitis

Answer 1

Infection of the bile duct

Question 2

Aetiology/causes of acute cholangitis

5

Answer 2

Obstruction of gallbladder or bile duct due to stones
ERCP
Tumours (e.g. pancreatic tumour or cholangiocarcinoma)
Bile duct stricture or stenosis
Parasitic infection (e.g ascariasis)

Question 3

Epidemiology of acute cholangitis

gender, age, ethnicity

Answer 3

Equal between sexes
Median age 50-60 yrs
More common in caucasians (follows gallstone disease)

Question 4

Presenting symptoms of acute cholangitis

3 + 2 + 1

Answer 4

Most present with Charcot’s Triad:
RUQ pain
Jaundice
Fever w/ rigors

Extended to form Reynolds’ Pentad:
Mental confusion
Septic shock

May also complain of pruritus

Question 5

Signs of acute cholangitis on physical examination

9

Answer 5

Fever
RUQ tenderness
Mild hepatomegaly
Jaundice
Mental status changes
Sepsis
Hypotension
Tachycardia
Peritonitis

Question 6

Types of investigations for acute cholangitis

2

Answer 6

Bloods

Imaging

Question 7

Investigations for acute cholangitis - bloods

6

Answer 7

FBC - high WCC
CRP/ESR - possibly raised
LFTs - raised ALP & GGP 
U&Es - may be signs of renal dysfunction
Blood cultures - check for sepsis
Amylase - may be raised if lower part of common bile duct is involved

Question 8

Investigations for acute cholangitis - imaging

4

Answer 8

Xray KUB - look for stones
Abdo US - look for stones & dilation of CBD
Contrast enhance CT/MRI - good for diagnosis
MRCP - may be necessary to detect non-calcified stones

Question 9

Initial management of acute cholangitis

2

Answer 9

Resuscitation
Maybe required if patient is in septic shock

Broad spectrum antibiotics
Given once blood cultures taken
Effective against anaerobes & Gram -ve (e.g cefuroxime + metronidazole)

Most patients respond to antibiotics by endoscopic biliary drainage usually required to treat underlying obstruction

Question 10

Staged management of acute cholangitis

2,2,3

Answer 10

STAGE 1 (mild)
Antimicrobial therapy
Percutaneous, endoscopic or operative intervention for non-responders (depends on aetiology)

STAGE 2 (moderate)
Early percutaneous or endoscopic drainage
Endoscopic biliary drainage recommended

STAGE 3 (severe)
Treatment of organ failure
Urgent percutaneous of endoscopic drainage
Definitive treatment required once clinical picture improves

Question 11

Complications of acute cholangitis

7 general + 4 intervention

Answer 11

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

Percutaneous or endoscopic drainage can lead to:
Intra abdominal or percutaneous bleeding
Sepsis
Fistulae
Bile leakage

Question 12

Prognosis of acute cholangitis

Answer 12

Mortality 17-40%