CBL - Biliary Sepsis

Question 1

What are the common causes of jaundice (hyperbilirubinemia)? [13]

Answer 1

1. Gallstones
2. Alcoholic hepatitis
3. Viral Hepatitis
4. Pancreatitis
5. Dyserythropoiesis (e.g. Sickle cell disease)
6. Biliary obstruction
7. Non-alcoholic steatohepatitis
8. Primary biliary cholangitis
9. Drugs
10. Sepsis and low perfusion states
11. Congestive heart failure
12. Malignancy
13. Liver infiltration

Question 2

What are the 3 basic pathophysiological mechanisms of unconjugated hyperbilirubinaemia? [3]

Answer 2

1. overproduction of bilirubin
2. reduced bilirubin uptake
3. impaired bilirubin conjugation

Question 3

What are the 3 basic pathophysiological mechanisms of conjugated hyperbilirubinaemia? [3]

Answer 3

1. biliary obstruction (extrahepatic cholestasis)
2. intrahepatic cholestasis
3. hepatocellular injury

Question 4

How does congestive heart failure cause jaundice and what kind of hyperbilirubinaemia does it cause (conjugated or unconjugated)? [2]

Answer 4

1. reduced hepatic blood flow and the delivery of bilirubin to hepatocytes
2. results in predominantly unconjugated hyperbilirubinemia

Question 5

What types of infiltrative processes into the liver can precipitate intrahepatic cholestasis? [4]

Answer 5

1. amyloidosis
2. lymphoma
3. sarcoidosis
4. tuberculosis

Question 6

What is Charcot’s Triad? [3]

Answer 6

Describes the clinical presentation of acute cholecystitis:

• Fever
• Abdominal pain
• Jaundice

Question 7

Define sepsis [3]

Answer 7

1. the presence of likely or confirmed infection
2. in addition to organ dysfunction
3. suggesting an abnormal physiological response to infection

Question 8

List the most common bacteria that cause acute cholecystitis/ biliary sepsis [5]

Answer 8

1. Gram-negative organisms:
   
   • Klebsiella species (approx. 20%)
   • Enterobacter species (approx. 10%)
2. Gram-positive organisms:
   
   • Enterococcus (approx. 10-20%)
3. Anaerobes:
   
   • Bacteroides
   • Clostridia

Question 9

What initial radiology investigations should be performed in all patients with suspected acute cholangitis/ biliary sepsis? [2]

Answer 9

1. Transabdominal ultrasound
2. Abdominal CT scan

Question 10

What are the pros and cons of using an intraabdominal ultrasound when investigating acute cholecystitis/biliary sepsis? [2]

Answer 10

1. Pros:
   
   • high specificity for the detection of stones
2. Cons:
   
   • lower sensitivity for detecting bile duct dilatation

Question 11

What are the pros and cons of using a CT scan when investigating acute cholecystitis/biliary sepsis? [3]

Answer 11

1. Pros:
   
   • a high sensitivity in the detection of bile duct dilatation
   • can identify biliary stenosis
2. Cons:
   
   • has a lower sensitivity for bile duct stones

Question 12

What empirical antibiotic therapy would be recommended for the treatment of acute cholecystitis/ biliary sepsis and what would each antibiotic target? [6]

Answer 12

Triple Therapy:

1. IV Amoxicillin → streptococci/enterococci cover
2. IV Metronidazole → gram -ve cover
3. IV Gentamicin → anaerobes cover