Ascending Cholangitis

Question 1

Define ascending cholangitis

Answer 1

refers to ascending infection to the biliary tree caused by the complete or partial biliary obstruction.

During an obstruction, stasis of fluid combined with increased intraluminal pressure allows the bacterial colonisation of the biliary tree to become pathological.

Question 2

Risk factors

Answer 2

gallstones
(RF: cholesterol, oral contraceptives, lipid rich diet)
recent biliary tract instrumentation (ERCP)
previous cholangitis
cholangiocarcinoma
Rare cause: pancreatitis, primary sclerosing cholangitis, ischemic cholangiopathy and parasitic infections

Question 3

Common infective organisms

Answer 3

E.coli
Klebsiella species
Enterococcus

Question 4

Clinical features

Answer 4

Charcot’s triad:
RUQ pain
fever with rigors
jaundice

add on with hypotension and confusion (mental changes) - Reynold’s pentad

complain of pruritus (skin itchiness)
due to bile accumulation

pale stool and dark urine
tachycardia

Question 5

Complications

Answer 5

septicaemia
liver abscess
acute renal failure

Question 6

Investigations

Answer 6

FBC
-WCC (leucocytosis)

LFT

• raised ALP
• raised Total Bilirubin (conjugated bilirubin)

Serum amylase (TRO pancreatitis)
CRP (inflammatory markers)

Blood cultures
-to obtain positve results before start of broad spectrum antibiotics

USS of bilirary tract

• bile duct dilatation
• look for stones

ERCP (diagostic and therapeutic)
MRCP (diagnostic only)
CT scan (other causes or complications)

Question 7

Management

Answer 7

IV fluids resuscitation
Keep NPO
Urinary catheter for ill patients for input and output monitoring
IV broad spectrum antibiotics (co-amoxiclav and metronidazole)
Emergency (very ill and hypotensive and confusion ) - biliary decompression to remove the cause of biliary tree obstruction
Biliary drainage