Cholangitis

Question 1

Outline the pathogenesis of acute cholangitis

Answer 1

• Cholelithiasis leading to choledocholithiasis and biliary obstruction OR
• Biliary stricture post-surgery or pancreatitis WITH
  
  • Seeding of the obstruction (portal vein?) and infection

Question 2

What are the risk factors for acute cholangitis?

Answer 2

• Age > 50
• Cholelithiasis
• Stricture (benign or malignant)
• Procedural injury of bile ducts

Question 3

What are the likely findings on history and examination in a patient with acute cholangitis?

Answer 3

• Charcot’s triad
  
  • Fever
  • RUQ pain
  • Jaundice
• RUQ tenderness

Question 4

What would be some sensible investigations to order in a patient suspected of acute cholangitis?

Answer 4

• FBE
• UEC
• LFTs/coags/albumin
• CRP
• Consider blood cultures
• ERCP (visualise obstruction)
• CT abdo

Question 5

What are the management prinicples for acute cholangitis?

Answer 5

• Address infection
  
  • IVAB - pip/taz or cip/met
• Pain management
  
  • Opioids
• Biliary decompression
  
  • ERCP and stenting
  • Surgical cholecystectomy/exploration may need to occur

Question 6

Outline the pathogenesis of primary sclerosing cholangitis

Answer 6

• Poorly understood. Likely to be an autoimmune cause
• Inflammation and fibrosis of the medium and large bile ducts leading to stricture formation, biliary stasis and predisposition to bacterial cholangitis
• Ongoing injury can lead to cirrhosis and ESLD

Question 7

What are the risk factors for primary sclerosing cholangitis?

Answer 7

• Inflammatory bowel disease (especially UC)
• Male
• FHx in FDR

Question 8

What are the common history findings in patients with primary sclerosing cholangitis?

Answer 8

• Risk factors (male, FHx, IBD)
• Abdo pain (RUQ or EG)
• Jaundice/pruritus (uncommon)
• Constitutional symptoms

Question 9

What might be some sensible investigations in a patient suspected of primary sclerosing cholangitis?

Answer 9

• LFT/albumin/coags
• FBE
• Autoantibodies (ANCA, ANA, RF)
• CT/ERCP/MRCP
• Investigations excluding other chronic liver disease causes

Question 10

What are the management principles for a patient with primary sclerosing cholangitis?

Answer 10

• Relieve symptoms
  
  • Colestyramine - sequesters bile acids and reduces pruritus
• Relieve strictures
  
  • ERCP and stenting
• End stage liver disease
  
  • Transplantation