Untitled Deck Flashcards
What is acute cholangitis aka ascending cholangitis?
A bacterial infection (typically E. coli) of the biliary tree usually secondary to biliary obstruction.
What are other causes of acute cholangitis?
Stasis of the biliary tree due to obstruction or biliary strictures (narrowing of bile duct- can occur after ERCP or due to cancer).
What are the risk factors for acute cholangitis?
History of cholelithiasis (gallstones in gallbladder), 50-60 years old, primary/secondary sclerosing cholangitis.
What are the main clinical features of acute cholangitis?
Charcot’s triad happens in 20-50% of patients with acute cholangitis: Fever (90% of patients), RUQ pain (70%), Jaundice (60%). They may also have pale stool and dark urine.
What are the additional 2 factors to make Reynold’s pentad?
Hypotension and confusion/mental status changes.
What other diagnostic feature is there of acute cholangitis?
Raised inflammatory markers.
What are the bedside investigations for acute cholangitis?
Abdominal exam - RUQ pain, jaundice; Basic observations.
What blood tests are done for acute cholangitis?
Urea & Creatinine → Raised; Increased WBC & CRP; LFTs → Hyperbilirubinemia, raised serum Transaminases (ALT) & Alkaline Phosphatase (ALP) primarily - suggesting cholangitis rather than a cholecystitis; Blood Cultures → check for sepsis & establish causative organism; ABG → Order on suspicion of sepsis = low bicarbonate, metabolic acidosis, raised lactate (severe).
Why in sepsis would you see low bicarbonate, metabolic acidosis, raised lactate?
In sepsis you have systemic inflammation - this results in hypotension and leads to tissue hypoxia → raised lactic acid → dissociates into H+ and lactate → increased acidity. Acidity results in increased consumption of bicarbonate therefore lowering its levels.
What is the first line investigation imaging in ascending cholangitis?
US to look for bile duct dilation and bile duct stones - it is very quick and accurate.
What is the best gold standard imaging intervention?
ERCP (Endoscopic Retrograde Cholangiopancreatography) - medical procedure and imaging - it combines endoscopy and X ray to visualize the biliary and pancreatic system.
What is the difference between MRCP and ERCP?
MRCP is non-invasive imaging and only for diagnostic purposes whereas ERCP is diagnostic and therapeutic. MRCP uses MRI with contrast whereas ERCP is endoscopic + X ray. ERCP needs anaesthesia, MRCP does not. ERCP has radiation and MRCP has no radiation.
What is first line management for acute cholangitis?
IV antibiotics - broad spectrum until exact causative agent is known.
What is second line management for acute cholangitis?
Endoscopic retrograde cholangiopancreatography (ERCP) drainage after 24-48 hours to relieve any obstruction.
What else is given for acute cholangitis?
IV fluids bolus and analgesia.
How are further episodes prevented?
Elective cholecystectomy when the patient is well.
What complications are there of acute cholangitis?
Acute pancreatitis, liver abscesses, sepsis.
What’s prognosis like after biliary drainage?
Most patients rapidly improve once biliary drainage is achieved. If decompression is delayed and patients have underlying medical conditions, prognosis is poor.
What factors are there for poor prognosis in acute cholangitis?
Hyperbilirubinaemia, high fever, leukocytosis, older age, hypoalbuminaemia.
What are differentials for acute cholangitis?
Acute hepatitis, gallstones, pancreatitis, appendicitis.
