Cholangitis/ Cholecystitis

Question 1

Define cholangitis

Answer 1

Obstruction of the common bile duct by stones

Question 2

Causes of cholangitis

Answer 2

When a stone moves to obstruct the common bile duct → Bile duct infection, biliary obstruction

(also caused by strictures, stenosis, parasites, tumours)

Question 3

Symptoms and signs of cholangitis

Answer 3

Symptoms: pyrexia, RUQ pain, jaundice, mental status change, tachycardia, hypotension

Signs: Charcot’s triad – RUQ pain, jaundice, rigors
(Reynold’ pentad when combined with ↓BP and confusion)

Question 4

Define cholecystitis

Answer 4

inflammation of the gallbladder

Question 5

Causes of cholecystitis

Answer 5

Types of Stones that block CBD

Question 6

Symptoms of cholecystitis

Answer 6

• Systemically unwell
• Fever
• Vomiting
• Prolonged abdominal pain - epigastric or RUQ
• Pain may be referred to right shoulder (due to diaphragmatic irritation)
• ±jaundice

Question 7

Signs of cholecystitis

Answer 7

• Tachycardia
• Pyrexia
• RUQ pain or epigastric tenderness
• May be guarding or rebound tenderness
• Murphy’s sign positive: 2 fingers over RUQ and ask pt to breathe in deeply, +ve if this causes pain and arrest of inspiration as inflamed GB hits fingers (must not cause the same pain in the LUQ)
  US → thick walled shrunken GB, pericholecystic fluid, stones, CBD dilation

Question 8

Investigations

Answer 8

Bloods

• FBC - high WCC in cholecystitis and cholangitis
• LFT - high ALP + GGT in ascending cholangitis
• Blood cultures
• Amylase (exclude pancreatitis)

Ultrasound

• Shows gallstones
• Increased thickness of gallbladder wall
• Dilatation of biliary tree

AXR - but only 10% of gallstones are radio-opaque

Other imaging - to exclude differentials (e.g. erect CXR, ERCP)

Question 9

Management

Answer 9

Conservative

• If only mild biliary colic - follow a low-fat diet

Medical

• NBM
• IV fluids
• Analgesia
• Anti-emetics
• Antibiotics (if infection is present)
• NOTE: if symptoms persist despite antibiotic treatment, suspect a localised abscess or empyema, which would require drainage
• If there is an obstruction, urgent biliary drainage by ERCP or via a percutaneous route is necessary

Surgical

• Laparoscopic Cholecystectomy

Question 10

Complications

Answer 10

Stones within the gallbladder

• Biliary colic
• Cholecystitis
• Gallbladder empyema
• Gallbladder cancer (RARE)

Stones outside the gallbladder

• Obstructive jaundice
• Pancreatitis
• Ascending cholangitis
• Cholecystoduodenal fistula
• Gallstone ileus
• Bouveret syndrome (gallstones cause gastric outlet obstruction)
• Mirizzi syndrome

Complications of cholecystectomy

• Bleeding
• Infection
• Bile leak
• Post-cholecystectomy syndrome
• Port-site hernia

Question 11

Prognosis

Answer 11

Gallstones do NOT cause symptoms most of the time

Surgery offers an excellent chance of cure if they were to become symptomatic