Cholangitis

Question 1

Define cholangitis

Answer 1

Infection of the biliary tree, most commonly caused by an obstruction

Question 2

Aetiology of Acute Cholangitis

Answer 2

Cholelithiasis -> choledocholithiasis and biliary obstruction
Iatrogenic biliary duct injury (commonly during cholecystectomy, ERCP) -> benign strictures
Primary/secondary sclerosing cholangitis
Chronic pancreatitis + stenosis and stricture of the distal common bile duct
Radiation or chemo induced
Liver pathology due to CBD obstruction

Infection: E. Coli

Question 3

Presenting symptoms of Acute Cholangitis

Answer 3

Fever
RUQ pain and tenderness
Jaundice
Pruritus
Mental status changes
Pale stools

Charcot’s: fever, RUQ pain, jaundice
Reynold’s pentad: fever, RUQ pain, jaundice, hypotension, confusion

Question 4

Signs of Acute Cholangitis

Answer 4

Obs: hypotension, pyrexia

General: jaundice, confusion

Abdo: RUQ tenderness

Question 5

Investigations for Acute Cholangitis

Answer 5

USS: confirm stones + dilated bile ducts
ERCP: stones/obstruction seen

LFTs - Bil raised, AST/ALT/ALP raised (obstructive picture)
FBC: Raised WCC and platelets
Renal function: Urea and Cr raised
VBG: metabolic acidosis
CRP/ESR: Raised
Blood cultures: positive

MRCP: mass impinging on biliary tree,stricture (if ERCP and USS cannot confirm)

Question 6

Management for Acute Cholangitis

Answer 6

1. Broad spectrum antibiotics e.g. piperacillin 3.375g IV
2. Bolus IV fluids
3. Correct electrolyte imbalances and coagulation abnormalities
4. Analgesia e.g. morphine 2.5-10mg IV every 2-6 hours when required
5. Biliary decompression with ERCP + drainage stent pTC or lithotripsy
6. Surgical decompression with laparoscopic choledochotomy

Question 7

Complications of Acute Cholangitis

Answer 7

Acute pancreatitis
Inadequate biliary drainage
Hepatic abscess

Question 8

Prognosis for Acute Cholangitis

Answer 8

Rapid improvement once biliary drainage is achieved
Poorer prognosis with those who have delay in decompression
Predictive factors of a poor prognosis: hyperbilirubinaemia, high fever, leucocytosis, odler age, albumin