Ascending Cholangitis

Question 1

What is another term for ascending cholangitis?

Answer 1

Acute cholangitis

Question 2

What is ascending cholangitis?

Answer 2

It is defined as a condition in which there is bacterial infection of the biliary tree – caused by a combination of both biliary outflow obstruction and biliary infection

Question 3

Which bacterial organism is associated with ascending cholangitis?

Answer 3

E.Coli

Question 4

What are the eight risk factors of ascending cholangitis?

Answer 4

Gallstone Disease

Iatrogenic Biliary Injury

Biliary Strictures

Pancreatic Cancer

Hepatocellular Carcinoma

Cholangiocarcinoma

Primary Sclerosing Cholangitis

Parasitic Infections

Question 5

What is the most common risk factor of ascending cholangitis?

Answer 5

Gallstone Disease

Question 6

What two parastitic infections associated with ascending cholangitis?

Answer 6

Roundworm

Liver fluke

Question 7

What are the nine clinical features of ascending cholangitis?

Answer 7

Fever

Nausea & Vomiting

Right Upper Quadrant Pain

Jaundice

Pruritus

Pale Stools

Dark Urine

Confusion

Hypotension

Question 8

What is Charcot’s triad?

Answer 8

It is defined as the presentation of fever, right upper quadrant pain and jaundice

Question 9

What is Reynold’s pentad?

Answer 9

It is defined as the presentation of Charcot’s triad with the additional two clinical features of hypotension and confusion

Question 10

What are the five investigations used to diagnose ascending cholangitis?

Answer 10

Blood Tests

Arterial Blood Gas (ABG)

Ultrasound Scans

CT Scans

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Question 11

What are the six blood test results indicative of ascending cholangitis?

Answer 11

Increased WCC Levels

Increased Bilirubin levels

Increased ALP Levels

Increased CRP Levels

Increased Urea Levels

Increased Creatinine Levels

Question 12

What are the two features of ascending cholangitis on ABG?

Answer 12

Metabolic acidosis

Increased lactate levels

Question 13

When are ultrasound scans used to diagnose ascending cholangitis?

Answer 13

They are the first line investigation

Question 14

What are the two features of ascending cholangitis on ultrasound scan?

Answer 14

Dilated Common Bile Duct

Gallstones

Question 15

When are CT scans, with contrast, used to diagnose ascending cholangitis?

Answer 15

They are the second line investigation used to diagnose ascending cholangitis, recommended when individuals present with negative ultrasound features however there is high clinical suspicion of cholangitis

Question 16

What is the feature of ascending cholangitis on CT scans with contrast?

Answer 16

Common bile duct dilation

It should be noted that non-calcified gallstones will not be visible

Question 17

What is the gold standard investigation of ascending cholangitis?

Answer 17

Endoscopic retrograde cholangiopancreatography (ERCP)

Question 18

What is ERCP?

Answer 18

It involves the insertion of an endoscope through the oesophagus, stomach and into the duodenum

In the duodenum, the endoscope is then guided through the sphincter of Oddi into the bile duct – where contrast is injected, and x-rays are then taken

Question 19

How is ERCP used to diagnose ascending cholangitis?

Answer 19

It is used to confirm diagnosis and determine the underlying pathological cause

Question 20

What is the pharmacological management option of ascending cholangitis?

Answer 20

IV Antibiotics

Question 21

Name three IV antibiotics used to manage ascending cholangitis

Answer 21

Piperacillin-tazobactam

Ticarcillin clavulanate

Ampicillin-sulbactam

Question 22

When is ERCP used to manage ascending cholangitis?

Answer 22

It is the first line management option in all cases of ascending cholangitis, which should be conducted 24-28 hours after diagnosis

Question 23

How is ERCP used to manage ascending cholangitis?

Answer 23

It involves sphincterotomy of the sphincter of Oddi, to aid bile drainage and passage of gallstones

Question 24

When is PTC used to manage ascending cholangitis?

Answer 24

It is the second line management option of ascending cholangitis, which should be conducted in cases where individuals are too unwell for ERCP, or it is unsuccessful

Question 25

What is PTC?

Answer 25

It involves placement of a biliary drain to decompress the biliary tree from above

This is performed by passing a needle though the skin and into the bile ducts

Question 26

What is the surgical management option of ascending cholangitis?

Answer 26

Laparoscopic Choledochotomy

Question 27

When is laparoscopic choledochotomy is used to manage ascending cholangitis?

Answer 27

It is the last resort management option of ascending cholangitis

Question 28

What is laparoscopic choledochotomy?

Answer 28

It involves incision of the common biliary duct and insertion of a drainage tube

Question 29

What are the three complications of ascending cholangitis?

Answer 29

Acute Pancreatitis

Inadequate Biliary Drainage

Hepatic Abscess Formation

Question 30

How do we differentiate between ascending cholangitis, acute cholecystitis and biliary colic?

Answer 30

In ascending cholangitis, individuals present with RUQ pain, fever and jaundice - with significant systemic features

In acute cholecystitis, individuals present with RUQ pain and fever - however systemic features are limited

In biliary colic, individuals present with RUQ pain, with absence of systemic features