Ascending Cholangitis

Question 1

Define Ascending Cholangitis

Answer 1

Inflammation & Infection of the common bile duct (-angi-) most commonly caused by biliary obstruction

Question 2

Explain the risk factors for ascending cholangitis

Answer 2

• Age over 50
• Choledocholithiasis (stones in CBD)
• Iatrogenic/benign stricture
  
  • post-surgery
  • ERCP
  • radiation
• Malignant strictures
  
  • pancreatic cancer
  • cholangiocarcinoma
• PSC strictures

Question 3

Explain the aetiology of ascending cholangitis

Answer 3

• Inflammation/infection of the common bile duct because of an infected stone/stricture in the common bile duct - infection usually occurs due to bacteria from the small intestine ascending into CBD as bile cannot flush them out)
• In cholangitis, the infection can easily spread up the CBD into the liver, and thence into the systemic circulation

Question 4

Summarise the epidemiology of ascending cholangitis?

Answer 4

• 9% of patients admitted to hospital with gallstone disease will have acute cholangitis
• Equal in males and females
• Median age of presentation: 50-60 yrs
• Racial distribution follows that of gallstone disease - fair-skinned people

Question 5

Recognize the presenting symptoms of acute cholangitis?

Answer 5

• Charcot’s triad (25-70% may have all 3 - not all required for diagnosis)
  
  • Fever with rigors
  • RUQ pain
  • Symptoms of jaundice (dark urine, pale stool, pruritus, yellow sclera/icterus)
• Mental status changes

Question 6

Identify the signs of ascending cholangitis on physical examination?

Answer 6

• Fever
• RUQ/Upper abdominal tenderness
• Jaundice
• Hypotension (if septic)
• Tachycardia

Question 7

Identify appropriate investigations for acute cholangitis

Answer 7

• 1st LINE -> Abdominal ultrasound to look for:
  
  • CBD dilation (may be physiologically dilated in cholecystectomised patients)
  • May visualise stones
• Bloods
  
  • FBC: Raised WCC
  • CRP: Raised
  • LFTs (raised bilirubin, ALP, ALT, AST)
  • Blood culture if septic
  • ABG for lactate if septic
  • Amylase: may be raised if the lower part of the common bile duct is involved
• Abdominal CT with intravenous contrast (if US is negative)
• ERCP if history of biliary disease

Question 8

Generate a management plan for acute cholangitis

Answer 8

• Broad-spectrum antibiotics (if sepsis is detected via blood culture)
• Intravenous fluids (restore electrolyte balance)
• Analgesia
• Correct coagulation abnormalities (Fresh frozen plasma)
• Urgent ERCP Biliary drainage: non-surgical
  
  • endoscopic procedure to remove the stone from the CBD
  • to be performed within 24-48hrs
  • Consider subsequent cholecystectomy for patients who had cholangitis with cholelithiasis.

Question 9

Identify the possible complications of ascending cholangitis

Answer 9

• Acute pancreatitis (due to distal CBD stones obstructing ampulla of vater/pancreatic duct)
• Hepatic abscess
• Liver failure
• Septic shock
• Post-procedure inadequate bile drainage

Question 10

Summarise the prognosis for patients with acute cholangitis

Answer 10

• Most patients experience rapid clinical improvement once adequate biliary drainage is achieved
• For patients with significant underlying medical conditions and those in whom decompression is delayed, prognosis is poorer.
• Mortality between 17-40%