Ascending Cholangitis

Question 1

Define cholangitis

Answer 1

infx of the biliary tree (often due to obstruction)

Question 2

What are the two types of cholangitis?

Answer 2

Cholangitis

Toxic cholangitis (septic cholangitis) = purulent biliary infx w. evidence of sepsis, hypotension, altered mental state , multi-organ failure

Question 3

Significance of toxic cholangitis

Answer 3

Can be fatal

Question 4

Key Px of cholangitis vs. toxic cholangitis

Ix that need to be ordered + key findings
Rx of ascending cholangitis
How long should ABX be taken? Method of administration?
Cx (4)
Important DDx

Answer 4

Charcot’s triad
• RUQ pain + tenderness (-ve Murphey’s sign)
• jaundice
• fever

Reynold's pentad (toxic) 
• Charcot's triad
• hypotension 
• altered mental status 
• (evidence of multi-organ failure)

Question 5

Other dx features of AC

Answer 5

alcoholic stool

pruritus

Question 6

5 (groups of) causes of cholangitis

Answer 6

• Cholelithiasis –> choledocholitiasis
• Iatrogenic
ERCP, cholecystectomy, radiation, chemo
• Chronic pancreatitis –> benign strictures
• Sclerosing cholangitis
• Other diseases
Acute pancreatitis, parasites, extrinsic compression (e.g. Mirizzi syndrome, blood clots), malignat stricures

Question 7

Most common cause for cholangitis

Answer 7

obstruction

Question 8

Risk factors for AC (6)

Answer 8

1. Age >50
2. cholelithiasis
3. benign strictures
4. malignant strictures
5. Hx sclerosing cholangitis (priamry/secondary)
6. iatrogeic bile duct injury

Question 9

Common infective organisms in AC (4+2)

Answer 9

• E. coli
• Klebsiella
• Enterobacter
• Enterococcus
• (+/- co-infx w. Bateriodetes + Clostridia)

Question 10

Pathogenesis of AC

Answer 10

• Obstruction allow seeding of the biliary tree (e.g. via portal vein) –> bacterial growth
• Sludge accumulates –> medium for bacterial growth
• Pressure accumulates in biliary tree –> promotes bacterial extravasation into the blood –> sepsis (if un-Rx ) –> toxic cholangitis

Question 11

Key Px of cholangitis vs. toxic cholangitis

Important DDx

Answer 11

Charcot’s triad
• RUQ pain + tenderness (-ve Murphey’s sign)
• jaundice
• fever

Reynold's pentad (toxic) 
• Charcot's triad
• hypotension 
• altered mental status 
• (evidence of multi-organ failure)

Question 12

Pathogenesis of AC

Answer 12

• Obstruction allow seeding of the biliary tree (e.g. via portal vein) –> bacterial growth
• Sludge accumulates –> medium for bacterial growth
• Pressure accumulates in biliary tree –> promotes bacterial extravasation into the blood –> sepsis (if un-Rx ) –> toxic cholangitis

Question 13

Ix that need to be ordered + key findings

Answer 13

• Basic bloods 
        - FBE = ↑WBC 
        - LFTs = ↑AST/ALT (ALP) 
        - UEC  = ↑U + C 
        - CRP = ↑
        - (CMP = ↓M + K)
• U/S = CBD dilation (+/- stones) 
• ERCP = stone 
• blood cultures 

If sepsis suspected:
• ABG = may show metabolic acidosis
• Coagulation = ↑PT

Question 14

Rx of ascending cholangitis

Answer 14

1. ABX
2. Drainage (most important) = ERCP (percutaneous/surgical if ERCP not possible)
3. Analgesia (opiates)

Question 15

How long should ABX be taken? Method of administration?

Answer 15

72h

IV –> downgrade to PO on d/c

Question 16

Key Px of cholangitis vs. toxic cholangitis

Answer 16

Charcot’s triad
• RUQ pain + tenderness (-ve Murphey’s sign)
• jaundice
• fever

Reynold's pentad (toxic) 
• Charcot's triad
• hypotension 
• altered mental status 
• (evidence of multi-organ failure)

Question 17

How long should ABX be taken? Method of administration?

Answer 17

72h

IV –> downgrade to PO on d/c

Question 18

Cx (4)

Answer 18

1. Sepsis (toxic cholangitis)
2. Acute pancreatitis (if obx at low enough level)
3. Hepatic abscess (rare)
4. Inadequate biliary drainage

Question 19

Important DDx

Answer 19

1. Acute cholecystitis = Murphey’s sign, US
2. Other biliary pathologies = usually not jaundied
3. PUD = normal LFTs
4. Pancreatitis = lipase, CT/MRI/US
5. Hepatic abscess = imaging, hepatomegaly
6. Pyelonephritis
7. RLL pneumonia