Cholangitis Flashcards
What is cholangitis?
An infection of the biliary tract
What is cholangitis associated with?
High morbidity and mortality if left untreated
What is cholangitis caused by?
Combination of biliary outflow obstruction and biliary infection
What happens during a biliary outflow obstruction?
Stasis of fluid combined with elevated intraluminal pressure allows bacterial colonisation of the biliary tree to become pathological
What kind of conditions can cause cholangitis?
Any condition which causes occlusion of the biliary tree has the potential to cause cholangitis
What are the most common causes of cholangitis?
- Gallstones
- ERCP
- Cholangiocarcinoma
What are the rarer causes of cholangitis?
- Pancreatitis
- Primary sclerosing cholangitis
- Ischaemic cholangiopathy
- Parasitic infections
What are the most common infective organisms implicated in cholangitis?
- E. Coli
- Klebsiella
- Enterococcus
What are the common presenting symptoms of cholangitis?
- RUQ pain
- Fever
- Jaundice
What are the other symptoms of cholangitis?
- Pruritis
- Pale stool
- Dark urine
What might a patient with cholangitis PMH contain?
- Gallstones
- Recent biliary tract instrumentation
- Previous cholangitis
What medications increase the risk of cholangitis?
- OCP
- Fibrates
What might be found on examination with cholangitis?
- Pyrexia
- Rigors
- Jaundice
- RUQ tenderness
- Confusion
- Hypotension
- Tachycardia
What eponymous syndromes are associated with cholangitis?
- Charcots triad
- Reynold’s Pentad
What is Charcots triad?
- Jaundice
- Fever
- RUQ pain
What is Reynold’s pentad?
- Jaundice
- Fever
- RUQ pain
- Hypotension
- Confusion
What is the result of cholangitis not being a complete diagnosis?
There is nearly always an underlying cause that should be identified and treated
What are the differential diagnoses for cholangitis?
- Biliary colic
- Cholecystitis
How can biliary colic be differentiated from cholangitis?
Biliary cold won’t have fever, leucocytosis, or jaundice
How can cholecystitis be differentiated from cholangitis?
Cholecystitis won’t have jaundice
What investigations should be done in cholangitis?
- Lab tests
- Imaging
What lab tests should be done in cholangitis?
- Routine bloods
- Blood cultures
What routine bloods should be done in cholangitis?
- FBC
- LFTs
What may be found on FBC in cholangitis?
Leucocytosis
What may be found on LFTs in cholangitis?
Raised ALP plus minus GGT with a raised bilirubin
In what % of cases of cholangitis are blood cultures +ve?
20%
What imaging may be done in cholangitis?
- Ultrasound of biliary tract
- ERCP (gold standard)
What may be found on ultrasound of biliary tract in cholecystitis?
- Bile duct dilatation
- Underlying cause, e.g. gallstones
How big is the common bile duct usually?
Less than 6mm
When might the common bile duct be larger?
- Elderly
- Those who have had previous cholecystectomy
What can ERCP be used for in cholangitis?
Both diagnosis and treatment
What may be required before ERCP can be performed?
MRCP (to obtain detailed imaging of biliary system prior to scoping_
What is involved in the immediate management of cholangitis?
If septic;
- Ensure IV accwess
- Fluid resus
- Routine bloods
- Blood cultures
- Broad spectrum IV antibiotics
What is the definitive management of cholangitis?
Endoscopic biliary decompression - removing cause of blocked biliary tree
When might endoscopic biliary decompression be done earlier?
For those who are deteriorating (compared to those responding well to antibiotic therapy)
How is endoscopic biliary decompression performed?
ERCP, with or without sphincterotomy and stenting
What is the second line investigation for patients who are too sick to tolerate ERCP?
Percutaneous transhepatic cholangiography
What may be required in the long-term treatment for cholangitis?
Cholecystectomy (if gallstones underlying cause)
What are the potential complications of ERCP?
- Repeated cholangitis
- Pancreatitis
- Bleeding
- Perforation
What is the mortality of cholangitis?
5-10%
What has been shown to improve patient outcomes in cholangitis?
Early ERCP and antibiotic therapy
What factors increase the mortality rate of cholangitis?
- Delayed diagnosis
- Liver failure
- Cirrhosis
- CKD
- Hypertension
- Female gender
- > 50 years
