GI: Ascending Cholangitis Flashcards
How does ascending cholangitis occur?
Bile outflow obstruction causes bile stasis and increased intraluminal pressure… allows bacterial colonisation and infection of the biliary tree.
Common causes of biliary tree occlusion:
- gallstone
- ERCP
- cholangiocarcinoma
Less common causes:
- pancreatitis
- primary sclerosing cholangitis
- ischaemic cholangiopathy
- parasitic infection
Name the 3 most common infective organisms causing ascending cholangitis.
- Escherichia coli (27%)
- Klebsiella spp. (16%)
- Enterococci (15%)
Describe the common presentation of a pt with ascending cholangitis.
Charcot’s triad (50-70%):
- RUQ pain
- fever
- jaundice
Reynolds’ pentad (10-20%):
- hypotension (due to septic shock)
- mental confusion
Other possible signs/symptoms:
- pruritis (bile salt accumulation)
- rigors
- tachycardia
What is the differential diagnosis for ascending cholangitis?
- Cholangitis (RUQ pain + fever without jaundice)
- Hepatitis, cirrhosis, liver failure, liver abscess
- mesenteric ischaemia
- pancreatitis
Which investigations would you perform on a Pt with suspected ascending cholangitis?
- Bloods
- FBC: increased WCC due to infection
- CRP: increased due to inflammation
- LFTs: increased ALT, increased bilirubin +/- increased GGT - post hepatic jaundice features
= UandEs: associated renal dysfunction - Imaging
- ERCP (gold standard): both diagnostic and therapeutic
- MRCP: 80-100% sensitivity for CBD stones
- USS biliary tract: will show bile duct dilation (>6mm) and may show underlying cause (e.g. gallstones - 30% sensitivity)
Describe how you would manage a Pt with ascending cholangitis.
ABCDE
- Fluid resuscitation
- IV antibiotics
- ERCP - emergency endoscopic drainage/decompression
+/- laparascopic cholecystectomy (once infection resolved) - recommended for all pts fit for surgery with symptomatic gallstone disease
What is the prognosis of ascending cholangitis?
Mortality rate 17-40% depending on comorbidities and age.
Early endoscopic drainage after Pt stabilisation significantly improves the prognosis.
Suggest possible complications of ascending cholangitis.
- liver abscesses, liver failure
2. bacteraemia and gram negative sepsis… septic shock, AKI and multi-organ failure