Ascending cholangitis additional info Flashcards
ascending cholangitis
The triad of acute pain, fever and jaundice is diagnostic of ascending cholangitis. Although this patient is not obviously jaundiced, she has an obstructive picture in her liver function tests. The serum amylase is usually normal in ascending cholangitis and if gallstones are present in the duct in theory there may be pancreatitis also. Acute hepatitis is associated with a hepatitic picture in liver function tests.
initial steps to manage ascending cholangitis and explain reason for each
- take blood cultures- as soon as they have been sent IV antibiotic treatment should be commenced as patients with ascending cholangitis can become septic and very ill quickly.
- analgesia and IV fluid
- erect chest radiograph - will help to rule out perforation
- arrange ultrasound examination of upper abdomen - will demonstrate if the biliary tree is dilated and an obstruction likely.
The initial treatment is intravenous antibiotics and intravenous fluid (often a lot of i.v. fluid is needed for resuscitation). Analgesia may also be required. Jaundiced patients are at an increased risk of acute kidney injury, so keep well hydrated. Especially during these initial investigations the patient is likely to be kept nil by mouth, making IV fluids even more important.
why may using an abdominal ultrasound prove technically difficult to visualise the biliary tree
due to bowel gas
can the common bile duct dilate after cholecystectomy?
The common bile duct can dilate after cholecystectomy, although not usually much above 7mm. A 10mm duct is dilated and ultrasound may show dilated intrahepatic ducts
what is the most likely cause of obstruction causing acute cholangitis
gallstones
which modalities are not good at detecting gallstones and why
X-ray imaging, including CT, is not good at detecting gallstones as on this imaging they are often isodense with the surrounding bile. Only 10% are well seen.
which non invasive tool is good at evaluating the biliary tree for diagnosis of aucte cholangitis especially if ultrasound is inconclusive
MRCP is a non-invasive tool which is good at evaluating the biliary tree and pancreatic ducts. It is preferred to ERCP when a ductal stone has not been proven yet, and if the stone has passed then it would be putting the patient to unnecessary risk to proceed direct to ERCP. However there can often be a delay in organising an MRCP and many clinicians would proceed with ERCP in a patient with evidence of ascending cholangitis and a dilated CBD.
Below is an image from an MRCP examination. Please match a label from A-H with structure below:
A - gallbladder
B - cystic duct
C - intrahepatic ducts
D - common hepatic duct
E - common Bile duct
F - gallstone
G - pancreatic duct
H - Duodenum
One MRCP confirms a probable calculus in a duct, which treatment is required? why? what is an alternative?
Urgent ERCP and sphincterotomy/stone retrieval
This stone needs to be removed as it is a source of sepsis and is unlikely to pass unaided. ERCP is the technique of choice although if this is not technically possible for some reason then these stones can be reached and stents inserted etc. at PTC (Percutaneous transhepatic cholangiogram) performed by interventional radiology. Open bile duct exploration is a last resort due to a high mortality risk.
ERCP with or without sphincterotomy and placement of a drainage stent allows for biliary tree decompression and stone extraction, and is the first-line therapy for acute cholangitis Percutaneous trans-hepatic cholangiography (PTC) can be performed initially for those who are poor ERCP candidates (e.g., status post-Roux-en-Y gastric bypass, presence of oesophageal stricture) or for those who do not obtain relief of bile duct obstruction from ERCP.
what are some complications of ERCP and sphincterectomy?
ERCP is an effective technique, allows instrumentation and is the safest method of dealing with an obstructing stone causing ascending cholangitis.
It does, however, have significant associated morbidity (about 5%) and mortality (especially in patients with ascending cholangitis). It can be associated with pancreatitis, infection, aspiration pneumonia.
Sphincterotomy can cause duodenal perforation and haemorrhage.
Biliary drain can cause hyponatraemia (low sodium) due to loss of salts causing dizziness
IV antibiotic management for ascending cholangitis
Start intravenous, broad-spectrum antibiotics for all patients with suspected or confirmed cholangitis, Bacteria are usually gram-negative, but gram-positive bacteria and anaerobes are also implicated in cholangitis. Once biliary drainage has been achieved and the patient shows clinical improvement, consider switching to oral antibiotics for the remainder of the antibiotic course.
Primary options
piperacillin/tazobactam: 4.5 g intravenously every 8 hours, may increase to 4.5 g every 6 hours in severe infections
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OR
imipenem/cilastatin: 500-1000 mg intravenously every 6 hours; or 1000 mg intravenously every 8 hours
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OR
cefuroxime: 750 mg intravenously every 6-8 hours, may increase to 1500 mg every 6-8 hours in severe infections
and
metronidazole: 500 mg intravenously every 8 hours
Secondary options
metronidazole: 500 mg intravenously every 8 hours
– AND –
ciprofloxacin: 400 mg intravenously every 8-12 hours
or
levofloxacin: 500 mg intravenously every 12-24 hours
or
gentamicin: 5-7 mg/kg intravenously every 24 hours
More
summarise ascending cholangitis
Acute cholangitis is an infection of the biliary tree that requires prompt diagnosis and treatment.
Most patients with acute cholangitis have fever, jaundice, and right upper quadrant pain (Charcot’s triad).
Acute cholangitis can quickly become an acute, septic, life-threatening infection that requires rapid evaluation and treatment.
The most common causes are choledocholithiasis and benign and malignant strictures.
Antibiotics alone do not provide sufficient treatment in the majority of patients. Drainage of the biliary tree is the most critical step in management.
If untreated, sepsis with shock, vascular collapse, multi-organ failure, and potentially death can occur.
abscess or deep seated infection
Here we know that the causative agent is sensitive to the antibiotic being used and that she has adequate drug levels based on therapeutic drug monitoring. It would be important to consider whether there is a collection of pus such as a gallbladder empyema which requires drainage.
Recommended time frames for ERCP
Recommended time frames vary according to severity:
Within 12 hours following admission: for patients with a deteriorating status (with persistent abdominal pain, hypotension despite intravenous fluid administration, fever >39°C [>102°F], worsening confusional state)[29][30]
Within 24 to 72 hours after admission: those for whom antibiotic treatment and medical management provide stability can have the decompression procedure.[2
which liver function test indicates biliary obstruction
elevated alkaline phosphatase and bilirubin
IV Piperacillin-tazobactam is a potent broad-spectrum antibiotic combining an extended-spectrum penicillin with a beta-lactamase inhibitor. It provides extensive coverage against Gram-positive bacteria, Gram-negative bacteria—including Pseudomonas aeruginosa—and anaerobic organisms. This makes it an excellent choice for empirical therapy in severe intra-abdominal infections like ascending cholangitis, where a mix of bacteria, including resistant strains, may be present. Using piperacillin-tazobactam covers common causative agents such as Escherichia coli, Klebsiella species, Enterococcus, and anaerobes like Bacteroides fragilis. Its efficacy in biliary tract infections has been well established, and it simplifies therapy by covering multiple organisms with a single agent. In this patient with ascending cholangitis, initiating intravenous piperacillin-tazobactam is the most appropriate management to provide comprehensive empirical coverage pending culture and sensitivity results.
