acute cholangitis Flashcards
definition of acute cholangitis
bacterial infection of the biliary tree due to biliary obstruction and stasis
infected and obstructed system
aetiology of acute cholangitis
most commonly occurs secondary to CBD obstruction by gallstones (choledocholithiasis)
other causes: benign bilary structures following bilary surgery or associated with chronic pancreatitis, PSC, HIV cholangiopathy and in pts with bilary stents, infection eg HIV, inflam (eg primary sclerosing cholangitis, IgG4-related sclerosing cholangitis)
bile duct obstruction due to cancer of the head of the pancreas or bile duct (cholangiocarninoma) - more likely cause after ERCP
extrinsic compression eg mirizzi syndrome
parasitic infection eg liver fluke, hydatid cyst, ascaris spp.
acute pancreatitis
periampullary duodenal diverticulum
contamination of bile with intestinal contents - manipulation of the biliary tract (eg papillotomy, stent placement, ERCP, liver transplantation), biliary-enteric fistula
in the far east, parts of the european and the mediterranean, bilary parasites can cause blockage and cholangitis
pathophysiology of acute cholangitis
biliary tract obstruction = bile stasis with increased intraductal pressure - bacterial translocation into bile ducts - bacterial infection ascends the biliary tract, even into the hepatic ducts
epidemiology of acute cholangitis
female more than male
up to 9% ots with cholelithiasis
50-60yrs
sx of acute cholangitis
triad of pain, fever and jaundice is diagnostic (Charcot’s triad) - not present in all pts
jaundice is cholestatic in type = urine dark, stool pale skin may itch
elderly pts may present with non-specific symptoms - confusion and malaise
reynold’s pentad - charcot cholangitis triad plus hypotension and mental status changes
Features of sepsis, septic shock, and multiorgan dysfunction may be present, depending on the severity of disease at presentation.
signs of acute cholangitis
unwell, febrile, tachycardic, elevated inflamm markers, jaundice
Ix for acute cholangitis
erect chest x-ray to rule out perforation
blood cultures - but give AB straight away because pts can become septic quickly
US will demonstrate if biliary tree is dilated and an obstruction likely
if US show common bile duct is dilated - investigate the distal common bile duct to determine cause of obstruction
MRCP used to investigate the biliary tree (prefered to ERCP because havent confirmed the stone yet)
WCC - show leukocytosis
blood cultures positive (E. coli, Enterococcus. faecalis, sometimes anaerobes) in about 30% of patients
Liver biochemistry shows a cholestatic picture with a raised serum bilirubin and alkaline phosphatase
US shows a dilated CBD and may show the cause of the obstruction
MRCP can further assess the site and cause of obstruction.
ERCP is the definitive investigation and will also allow biliary drainage. It will show the site of obstruction and the cause, and bile can be sampled for culture and cytology (if a malignant cause is suspected).
dx of acute cholangitis
diagnosed on systemic signs of inflammation - fever, leukocytosis, increased CRP. and signs of cholestasis - jaundice, raised GGT and ALP. and/or characteristic imaging findings (dilated CBD, periductal inflammation)
Diagnostic criteria for acute cholangitis
- Systemic signs of inflammation
- Fever and/or chills with rigors
- Laboratory findings: ↑ WBC, CRP
Signs of cholestasis
- Jaundice
- LFTs: signs of cholestasis (↑ bilirubin, ↑ GGT, ↑ ALP, ↑ ALT)
Imaging findings
- Biliary dilatation
- Evidence of underlying etiology (e.g., choledocholithiasis, biliary stricture, biliary stent, etc.)
Interpretation
- Suspected diagnosis: ≥ 1 sign of inflammation PLUS either ≥ 1 sign of cholestasis OR ≥ 1 characteristic imaging findings
- Definite diagnosis: ≥ 1 sign of inflammation PLUS ≥ 1 sign of cholestasis PLUS ≥ 1 characteristic imaging findings
tests to support dx of acute cholangitis
CBC: leukocytosis with left shift
CRP: elevated
LFTs: signs of cholestasis (↑ bilirubin, ↑ GGT (gamma glutamyl transferase), ↑ ALP, ↑ALT)
Blood cultures (2 sets): Obtain before administering antibiotics (especially in febrile patients). [1] THINK THIS IS WRONG - CAPSULE SAID DO IMMEDIATELY, THIS IS FROM AMBOSS
Bile cultures: obtain during biliary drainage procedure
tests to assess severity of acute cholangitis
Blood gas analysis: PaO2/FiO2 ratio < 300 in severely ill patients
BMP (basic metabolic panel): AKI (acute kidney injury), electrolyte derangements in patients with severe disease
PT/INR: coagulopathy in patients with severe disease
imaging for acute cholangitis
goal of imaging is to evaluate biliary obstruction that may have precipitated cholangitis
RUQ US - preferred 1st line imaging. see dilated CBD, thickened BD walls, evidence of underlying aetiology: choledocholithiasis, biliary stricture (focal narrowing of the bile duct with dilation of the prox biliary tree), biliary tumour (intraluminal mass in the bile duct)
CV with IV contrast - confirmatory imaging if US is inconclusive, rule out ddx. concentric thickening and heterogenous enhancement of the walls of biliary tree, bile duct dilation, periductal oedema, evidence of underlying cause (choledocholithiasis, biliary tumour, biliary-enteric fistula, hydatid cyst), evidence of complications (pericholecystic or liver abscess, portal vein thrombosis)
MRI - similar to CT
Mx of acute cholangitis
initial treatment is IV AB and IV fluid (jaundice pts increased risk of acute kidney injury - need hydration)
analgesia
NBM (nil by mouth) - IV fluids more important
if detect calculus (stone) in distal common bile duct - need to be removed because source of sepsis - ERCP used. If not technically possible the the stones can be reached and stents inserted (eg if cancer of head of pancreas/common bile duct (CBD))
Open bile duct exploration is a last resort due to a high mortality risk.
Antibiotics are continued after biliary drain-age until symptom resolution, usually 7–10 days.
Bacterial infection may be polymicrobial and a suitable antibiotic regimen is a third-generation cephalosporin, e.g. cefotaxime (ciprofloxacin if allergic), plus metronidazole. An alternative regimen is amoxicillin, gentamicin (with appro-priate monitoring) and metronidazole. In endemic areas primary parasite infection must also be treated
correct clotting - because need bile to absorb the fat soluble vitamins eg vit k which is needed in clotting factors
treat the sepsis - because become septic quickly because it is an enclosed space - sepsis 6
urgent ERCP to decompress the biliary system - ERCP goes through the duodenum. If cant do ERCP can do Percutaneous transhepatic cholangiography through liver into the biliary system
complications of acute cholangitis
pericholecystic or liver abscess, portal vein thrombosis.
sepsis, septic shock, MODS
pericholecystic abscess
biliary stricture
px of acute cholangitis
surgery is good treatment
