Ascending/acute cholangitis (GI) Flashcards
Define ascending cholangitis.
Infection of the biliary tree, most commonly caused by obstruction
What type of infection is present in ascending cholangitis?
Bacterial infection - typically E. coli
What is ascending cholangitis now known as?
Acute cholangitis
What is the most common cause of ascending cholangitis?
Cholelithiasis (gallstones) leading to choledocholithiasis and biliary obstruction
What are the common causes of ascending cholangitis? (2)
- choledocholithiasis
- benign/malignant strictures (narrowing of bile duct after ERCP/cancer)
What are some secondary causes of ascending cholangitis? (10 - low yield)
- common bacteria (E. coli, Klebsiella, Enterococcus)
- bile duct injury (iatrogenic), benign strictures
- chronic pancreatitis
- radiation-induced biliary injury
- parasite: Ascaris lumbricoides or Fasciola hepatica
- extrinsic compression of the biliary tree due to adenopathy
- fibrosis of the papilla
- blood clots
- Sump syndrome
- malignant biliary strictures
What do 50-70% of patients with ascending cholangitis present with?
Charcot’s triad - RUQ pain, fever and jaundice
What is the more severe, life-threatening form of ascending cholangitis?
Toxic cholangitis or cholangitis with sepsis - purulent biliary tree contents, as well as evidence of sepsis, hypotension, multi-organ failure and mental status changes
What is primary sclerosing cholangitis? (3)
- chronic inflammation
- progressive fibrosis and stricturing of medium and large-sized extrahepatic and/or intrahepatic bile ducts
- associated with IBD (UC)
What are the clinical features of ascending cholangitis? (2 + 2)
- Charcot’s triad - RUQ pain/tenderness, fever, jaundice
- Reynold’s pentad - RUQ pain/tenderness, fever, jaundice, hypotension, confusion
- pale stools
- pruritus
What is Charcot’s triad (ascending cholangitis)?
Seen in 50-70% of patients:
- fever (90%)
- RUQ pain (70%)
- jaundice
What is Reynold’s pentad (ascending cholangitis)?
- fever
- RUQ
- jaundice
- hypotension
- confusion (+ mental status changes)
What is another diagnostic feature of ascending cholangitis?
Raised inflammatory markers
What are some risk factors for ascending cholangitis? (6)
- age >50
- cholelithiasis (gallstones in gallbladder)
- primary/secondary sclerosing cholangitis
- benign/malignant stricture
- post-procedure injury (e.g. ERCP)
- HIV
What are the first-line investigations for ascending cholangitis? (5)
- abdominal ultrasound
- FBC - high WCC&CRP
- serum urea/creatinine - high
- ABG
- LFTs
What is the main first-line investigation for ascending cholangitis and what would we see?
Abdominal ultrasound - dilated bile duct, common bile duct stones
What might serum LFTs show in ascending cholangitis?
- hyperbilirubinaemia
- raised serum transaminases (GGT) and ALP
- ALT may also be raised
What do abnormal LFTs suggest in cholecystitis vs ascending cholangitis?
Abnormal LFTs suggest ascending cholangitis rather than acute cholecystitis
What might ABG show in ascending cholangitis?
Metabolic (lactic) acidosis - ordered on suspicion of sepsis (low HCO3, raised lactate)
What is checked in blood cultures for ascending cholangitis?
Check for sepsis, and establish causative organism
Why do we do ERCP to investigate ascending cholangitis?
- best first investigation: diagnostic and therapeutic
- helps observe bile duct stone but may cause pancreatitis
What are some differential diagnoses for ascending cholangitis? (8)
- acute cholecystitis - no jaundice, +ve Murphy’s sign
- peptic ulcer disease
- acute pancreatitis - elevated lipase/amylase
- hepatic abscess
- acute pyelonephritis
- right LL pneumonia
- acute appendicitis
- HELLP syndrome (pre-eclampsia)
What is the diagnostic criteria for ascending cholangitis? (3)
1 from each of:
- systemic inflammation (fever or neutrophilia)
- cholestasis (jaundice or abnormal LFTs)
- imaging (biliary dilation, stricture, stone, stent)
How do we treat for sepsis in ascending cholangitis?
Sepsis 6:
Give:
- IV fluids
- IV Abx
- high flow oxygen
Take:
- lactate
- urine output
- blood cultures
How do we manage acute ascending cholangitis?
-
IV broad-spectrum Abx + intensive medical management:
- tazobactam, imipenem, metronidazole - until cultures obtained
- IV potassium/magnesium if needed, repletion of coagulation factors with FFP+platelets if needed
- opioid analgesic + paracetamol
- biliary decompression - if deteriorating status
- non-operative (1st-line): ERCP +/- sphincterotomy + drainage stent
- operative (less preferred): laparoscopic choledochotomy or cholecystectomy
What is first- and second-line treatment for ascending cholangitis?
- 1 (initial management): IV broad-spectrum Abx until causative organism known
- 2: ERCP drainage after 24-48h to relieve obstruction
- AND IV fluids
- AND analgesia
When do we do lithotripsy for ascending cholangitis?
For bile duct stones too large/difficult to move
How are further episodes of ascending cholangitis prevented?
Elective cholecystectomy
What are some complications of ascending cholangitis? (5)
- acute pancreatitis (obstruction of pancreatic duct/junction of PD+CBD)
- liver abscess
- sepsis
- pneumonia (after ERCP)
- haemorrhage/perforation (after sphincterotomy)
What is the prognosis of ascending cholangitis like after biliary drainage?
- most patients rapidly improve after ERCP
- if decompression is delayed and patients have underlying medical conditions, prognosis is poor
What are the factors for poor prognosis in ascending cholangitis? (5)
- hyperbilirubinaemia
- high fever
- leukocytosis
- older age
- hypoalbuminaemia
