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Year 3 > Ascending/acute cholangitis (GI) > Flashcards

Ascending/acute cholangitis (GI) Flashcards

1
Q

Define ascending cholangitis.

A

Infection of the biliary tree, most commonly caused by obstruction

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2
Q

What type of infection is present in ascending cholangitis?

A

Bacterial infection - typically E. coli

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3
Q

What is ascending cholangitis now known as?

A

Acute cholangitis

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4
Q

What is the most common cause of ascending cholangitis?

A

Cholelithiasis (gallstones) leading to choledocholithiasis and biliary obstruction

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5
Q

What are the common causes of ascending cholangitis? (2)

A
  • choledocholithiasis
  • benign/malignant strictures (narrowing of bile duct after ERCP/cancer)
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6
Q

What are some secondary causes of ascending cholangitis? (10 - low yield)

A
  • 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
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7
Q

What do 50-70% of patients with ascending cholangitis present with?

A

Charcot’s triad - RUQ pain, fever and jaundice

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8
Q

What is the more severe, life-threatening form of ascending cholangitis?

A

Toxic cholangitis or cholangitis with sepsis - purulent biliary tree contents, as well as evidence of sepsis, hypotension, multi-organ failure and mental status changes

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9
Q

What is primary sclerosing cholangitis? (3)

A
  • chronic inflammation
  • progressive fibrosis and stricturing of medium and large-sized extrahepatic and/or intrahepatic bile ducts
  • associated with IBD (UC)
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10
Q

What are the clinical features of ascending cholangitis? (2 + 2)

A
  • Charcot’s triad - RUQ pain/tenderness, fever, jaundice
  • Reynold’s pentad - RUQ pain/tenderness, fever, jaundice, hypotension, confusion
  • pale stools
  • pruritus
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11
Q

What is Charcot’s triad (ascending cholangitis)?

A

Seen in 50-70% of patients:

  • fever (90%)
  • RUQ pain (70%)
  • jaundice
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12
Q

What is Reynold’s pentad (ascending cholangitis)?

A
  • fever
  • RUQ
  • jaundice
  • hypotension
  • confusion (+ mental status changes)
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13
Q

What is another diagnostic feature of ascending cholangitis?

A

Raised inflammatory markers

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14
Q

What are some risk factors for ascending cholangitis? (6)

A
  • age >50
  • cholelithiasis (gallstones in gallbladder)
  • primary/secondary sclerosing cholangitis
  • benign/malignant stricture
  • post-procedure injury (e.g. ERCP)
  • HIV
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15
Q

What are the first-line investigations for ascending cholangitis? (5)

A
  • abdominal ultrasound
  • FBC - high WCC&CRP
  • serum urea/creatinine - high
  • ABG
  • LFTs
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16
Q

What is the main first-line investigation for ascending cholangitis and what would we see?

A

Abdominal ultrasound - dilated bile duct, common bile duct stones

17
Q

What might serum LFTs show in ascending cholangitis?

A
  • hyperbilirubinaemia
  • raised serum transaminases (GGT) and ALP
  • ALT may also be raised
18
Q

What do abnormal LFTs suggest in cholecystitis vs ascending cholangitis?

A

Abnormal LFTs suggest ascending cholangitis rather than acute cholecystitis

19
Q

What might ABG show in ascending cholangitis?

A

Metabolic (lactic) acidosis - ordered on suspicion of sepsis (low HCO3, raised lactate)

20
Q

What is checked in blood cultures for ascending cholangitis?

A

Check for sepsis, and establish causative organism

21
Q

Why do we do ERCP to investigate ascending cholangitis?

A
  • best first investigation: diagnostic and therapeutic
  • helps observe bile duct stone but may cause pancreatitis
22
Q

What are some differential diagnoses for ascending cholangitis?

A
  • acute cholecystitis - no jaundice, +ve Murphy’s sign
  • peptic ulcer disease
  • acute pancreatitis - elevated lipase/amylase
  • hepatic abscess
  • acute pyelonephritis
  • acute appendicitis
  • right LL pneumonia
  • HELLP syndrome (pre-eclampsia)
23
Q

What is the diagnostic criteria for ascending cholangitis? (3)

A

1 from each of:

  • systemic inflammation (fever or neutrophilia)
  • cholestasis (jaundice or abnormal LFTs)
  • imaging (biliary dilation, stricture, stone, stent)
24
Q

How do we treat for sepsis in ascending cholangitis?

A

Sepsis 6:

Give:

  • IV fluids
  • IV Abx
  • high flow oxygen

Take:

  • lactate
  • urine output
  • blood cultures
25
Q

How do we manage acute ascending cholangitis?

A
  • 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
26
Q

What is first- and second-line treatment for ascending cholangitis?

A
  • 1 (initial management): IV broad-spectrum Abx until causative organism known
  • 2: ERCP drainage after 24-48h to relieve obstruction
    • IV fluids
    • analgesia
27
Q

When do we do lithotripsy for ascending cholangitis?

A

For bile duct stones too large/difficult to move

28
Q

How are further episodes of ascending cholangitis prevented?

A

Elective cholecystectomy

29
Q

What are some complications of ascending cholangitis? (5)

A
  • acute pancreatitis (obstruction of pancreatic duct/junction of PD+CBD)
  • liver abscess
  • sepsis
  • pneumonia (after ERCP)
  • haemorrhage/perforation (after sphincterotomy)
30
Q

What is the prognosis of ascending cholangitis like after biliary drainage?

A
  • most patients rapidly improve after ERCP
  • if decompression is delayed and patients have underlying medical conditions, prognosis is poor
31
Q

What are the factors for poor prognosis in ascending cholangitis? (5)

A
  • hyperbilirubinaemia
  • high fever
  • leukocytosis
  • older age
  • hypoalbuminaemia

Year 3 (95 decks)

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