GI: Ascending Cholangitis Flashcards

1
Q

How does ascending cholangitis occur?

A

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
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2
Q

Name the 3 most common infective organisms causing ascending cholangitis.

A
  1. Escherichia coli (27%)
  2. Klebsiella spp. (16%)
  3. Enterococci (15%)
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3
Q

Describe the common presentation of a pt with ascending cholangitis.

A

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
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4
Q

What is the differential diagnosis for ascending cholangitis?

A
  • Cholangitis (RUQ pain + fever without jaundice)
  • Hepatitis, cirrhosis, liver failure, liver abscess
  • mesenteric ischaemia
  • pancreatitis
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5
Q

Which investigations would you perform on a Pt with suspected ascending cholangitis?

A
  1. 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
  2. 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)
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6
Q

Describe how you would manage a Pt with ascending cholangitis.

A

ABCDE

  1. Fluid resuscitation
  2. IV antibiotics
  3. ERCP - emergency endoscopic drainage/decompression

+/- laparascopic cholecystectomy (once infection resolved) - recommended for all pts fit for surgery with symptomatic gallstone disease

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7
Q

What is the prognosis of ascending cholangitis?

A

Mortality rate 17-40% depending on comorbidities and age.

Early endoscopic drainage after Pt stabilisation significantly improves the prognosis.

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8
Q

Suggest possible complications of ascending cholangitis.

A
  1. liver abscesses, liver failure

2. bacteraemia and gram negative sepsis… septic shock, AKI and multi-organ failure

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