Ascending Cholangitis/Acute

Question 1

Definition

Answer 1

Infection of the biliary tree commonly caused by gallstones (cholelithiasis) which move into the common bile duct (choledocholithiasis). Obstruction causes cholestasis, which then cause an ascending infection.
- E.COLI most common pathogen
- Surgical emergency + has high mortality rate due to sepsis + septicaemia

Question 2

Epidemiology

Answer 2

4 F’s
Age > 50

Question 3

Risk factors

Answer 3

Gall stones: most common predisposing factor
Stricture of the biliary tree: benign or malignant
Post procedure injury: of the bile ducts e.g. post ERCP

Question 4

Aetiology (Causes of obstruction to biliary flow)

Answer 4

Gallstones
Biliary strictures
Sclerosing cholangitis
Cholangiocarcinoma
(All cause obstruction to biliary flow)
Iatrogenic instrumentation: e.g. ERCP can cause biliary injury and contamination may lead to cholangitis

Question 5

Most common infectious organisms to cause AC

Answer 5

1. E. coli
2. Klebsiella species
3. Enterococcus species

Question 6

Pathophysiology

Answer 6

Normally bacteria tree as bile + pancreatic juices flush it down. Due to prolonged bile duct blockage, bacteria can climb up from the GI tract and cause biliary tree infection + consolidation
Proximal to the obstruction, the duct is under high pressure -> space between the cell lining, the duct can widen = bacteria and bile can get into blood stream = SEPSIS + JAUNDICE -> SEPTIC SHOCK (blood vessels become leaky leading to hypotension -> less blood flow to the brain = confusion)

Question 7

Signs

Answer 7

CHARCOTS TRIAD:
- RUQ pain
- Fever
- Jaundice
REYNOLDS PENTAD: Associated with biliary sepsis
- Fever
- RUQ pain
- Jaundice
- Hypotension
- Confusion
Normally absence of Murphy’s sign
Scleral icterus
Pyrexia

Question 8

Symptoms

Answer 8

RUQ abdo pain
Jaundice
Fever (MC)
Itchy
Dark urine and pale stool (cholestasis)
Confusion

Question 9

Diagnosis

Answer 9

FIRST LINE: USS of abdo
- CBD dilation + gallstones
FBC: leucocytosis with neutrophilia
LFTs: obstructive jaundice with raised ALP > ALT and bilirubin
ABG: sepsis will show metabolic acidosis
GOLD STANDARD: MRCP (best preintervention management)

Question 10

Treatment

Answer 10

FIRST LINE: ERCP (24-48 hours) then laparoscopic cholecystectomy once stable to prevent recurrence
Consider risk of sepsis =
- Biliary obstruction -> backflow of biliary sludge = stasis is the basis
- IV antibiotics: broad spec with gram -ve and anaerobic cover = CEFOTAXIME and METRONIDAZOLE for 4-7 days
- IV fluids

Question 11

Complications

Answer 11

SEPSIS
Acute pancreatitis
Hepatic abscess
Risks of ERCP: duodenal perforation, pancreatitis, biliary sepsis, intra abdominal bleeding