Ascending Cholangitis

Question 1

What is ascending cholangitis?

Answer 1

Bacteria from the duodenum (typically e.coli) ascends into the bile ducts causing infection and inflammation.

Question 2

What physiological action usually prevents ascending cholangitis?

Answer 2

Bile travelling down the duct flushing it out.

Therefore biliary stasis is a risk factor

Question 3

What are risk factors of ascending cholangitis?

Answer 3

Gallstones (Four ‘Fs’ - Fat, Female, Fertile, Forty) in the common bile duct preventing flow of bile
Stricture of the common bile duct

Question 4

What are the risk factors for gallstones?

Answer 4

Female
Obesity (Fat)
Pregnancy (Fertile)
Age (Forty)

Question 5

What bacteria is most commonly the cause of ascending cholangitis?

Answer 5

Usually enteric (from duodenum):
E. coli
Klebsiella
Enterococcus

Question 6

What are the symptoms of ascending cholangitis?

Answer 6

Charcot’s Triad - Fever (90%), RUQ pain (70%), Jaundice (60%)*
Triad (20-50%)

*If increased pressure causes bile to leak into blood stream

Septic shock (Hypotension, Confusion) - All 5 = Reynolds’ Pentad

Also raised inflammatory markers

Pale stool and dark urine

Question 7

What is in Charcot’s triad?

Answer 7

Fever
RUQ Pain
Jaundice

Question 8

How is the diagnosis made?

Answer 8

Bloods (CRP, ESR, ECC, Bilirubin)
Ultrasound - 1st line
Endoscopic Retrograde Cholangiopancreatography (ERCP)

Question 9

Treatment?

Answer 9

Rehydration
IV Antibiotics
ERCP after 24-48 hours to relieve any obstruction

Question 10

How can gallstones be removed?

Answer 10

ERCP suction (diagnostic and therapeutic)
Shockwave lithotripsy
Cholecystectomy (removal of gallstones - done more for acute cholecystitis)

Question 11

Are the enteric bacteria responsible e.g. e.coli, gram negative or gram positive?

Answer 11

Gram-negative

Question 12

What is Charcot’s triad used to detect?

Answer 12

Ascending cholangitis

Question 13

Ascending cholangitis is defined as baterial infection of what?

Answer 13

The bile duct

Question 14

What is included in the Reynold pentad of cholangitis?

Answer 14

Charcot triad (RUQ pain, jaundice, pyrexia)
+
Altered mental status
Shock (hypotension)

Question 15

What intervention can be used both diagnostically and therapeutically?

Answer 15

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Question 16

What other symptom might patients report outside of Charcot’s triad and why does this occur?

Answer 16

Pale, foul-smelling diarrhoea (steatorrhea) since bile is unable to enter the GI tract and digest fat.

Dark urine - billirubin

Question 17

What sign is seen in ascending cholangitis but not cholecystitis?

Answer 17

Jaundice

There would be fever and RUQ pain but not jaundice as bile flow from the liver is not obstructed

Question 18

What is choledocholithiasis?

Answer 18

Stone in the common bile duct - presents with nausea, vomiting RUQ pain but pain lasts for only a few hours at a time.