Cholangitis

Question 1

What is cholangitis?

Answer 1

Infection of the biliary tract

There is a combination of biliary outflow obstruction and biliary infection.

The stasis of fluid during the obstruction leads to increased intraluminal pressure and allows for bacterial colonisation of the biliary tree

Question 2

Causes of cholangitis

Answer 2

Anything that occludes the biliary tree

Most common…

Gallstones

ERCP (iatrogenic)

Cholangiocarcinoma

Less common…

Primary sclerosing cholangitis

Ischaemic cholangiopathy

Pancreatitis

Parasitic infections

Question 3

Most common causative infective organisms in cholangitis

Answer 3

E. Coli

Klebsiella spp.

Enterococcus

Question 4

Clinical features

Answer 4

RUQ pain

Fever

Jaundice

Pruritus

Pale stools

Dark urine

Question 5

Usual PMH of cholangitis

Answer 5

Gallstones

Recent ERCP

Previous cholangitis

Oral COCP

Fibrates

Lipid rich diet

Question 6

Examination findings

Answer 6

Pyrexia

Rigors

Jaundice

RUQ tenderness

Confusion

Hypotension

Tachycardia

Sepsis

Question 7

Two common eponymous syndromes of cholangitis

Answer 7

Charcot’s triad

Reynold’s Pentad

Question 8

Explain Charcot’s triad

Answer 8

Jaundice

Fever

RUQ pain

Question 9

Explain Reynold’s pentad

Answer 9

Jaundice

Fever

RUQ pain

Hypotension

Confusion

Question 10

Dx

Answer 10

Biliary colic

Cholecystitis

Question 11

Lab tests

Answer 11

Routine bloods

FBC (leucocytosis)

LFTs (raised ALP +/- GGT and raised bilirubin)

Blood cultures

Question 12

Imaging

Answer 12

USS of biliary tract

ERCP (Gold standard investigation + therapeutic)

Question 13

USS findings

Answer 13

Bile duct dilation

Common bile duct is suually less than 6mm in size.

Any diameter bigger suggests dilation.

Should also find a gallstone if that is the cause

Question 14

ERCP findings

Answer 14

Note that many endoscopists may require MRCP prior to intervention.

Question 15

General management

Answer 15

Since they might present with sepsis do SEPSIS 6

IV acces with fluid resus

Routine bloods

Blood cultures

Broad spectrum IV antibiotics like co-amoxiclav +/- metronidazole as per local guidelines.

Question 16

Defintive management

Answer 16

Endoscopic biliary decompression to remove that cause.

ERCP with or without a sphincterotomy and stenting should clear obstruction.

Patients too poor to tolerate ERCP you can do percutaneous transhepatic cholangiograpy.

Question 17

What long term intervention may be required?

Answer 17

Cholecystectomy if gallstones were the underlying cause

Question 18

Complications of ERCP

Answer 18

Repeated cholangitis

Pancreatitis

Bleeding

Perforation

Question 19

Prognosis

Answer 19

Mortality of cholangitis is around 5-10%

Early ERCp and early abx improve outcome.