Acute cholangitis

• What is acute cholangitis also known as?

  Ascending cholangitis
• What is acute cholangitis?

  Severe, acute infection & inflammation of the biliary tree

  Most commonly caused by obstruction
• What are the RFs of acute cholangitis?

  Hx of gallstones

  Prior biliary surgery

  Presence of biliary stent

  Immunosuppression

  Pancreatitis

  Presence of biliary tract tumour
• What are the primary causes of acute cholangitis?

  Biliary calculi (stones) - 50%

  Benign biliary stricture - 20% (can be congenital, post-infectious, or due to an inflammatory process)

  Malignancy - 10-20% (can originate from gallbladder, bile duct, ampulla, duodenum, or pancreas)
• What are the signs & symptoms of acute cholangitis?

  Right upper quadrant pain

  Fever

  Jaundice

  Hypotension

  Mental confusion

  Charcot's triad (right upper quadrant pain, fever, jaundice)
• Fill in the blanks

  A) Right upper quadrant

  B) Right upper quadrant

  C) Epigastric of right upper quadrant

  D) Steady

  E) severe

  F) Steady

  G) severe

  H) Colicky

  I) intermittent

  J) Present

  K) May be present

  L) Absent

  M) Present

  N) May be present

  O) Absent

  P) Common

  Q) Common

  R) Rare

  S) Absent

  T) Present

  U) Absent

  V) Biliary obstruction

  W) Gallbladder inflammation

  X) Gallstone in cystic duct

  Y) Sepsis

  Z) Empyema

  [) gangrene

  
• What are the DDx of acute cholangitis?

  Acute cholecystitis

  Acute hepatitis

  Gallstones

  Pancreatitis

  Perforated peptic ulcer

  Acute appendicitis
• What are the Inx of acute cholangitis?

  Obs

  Full Hx & examination

  ABG

  Bloods (FBC, U&Es, LFTs, CRP, cultures, coag)

  Abdominal USS

  CT/MRI
• What is the management of acute cholangitis?

  Resus with IV fluids & Abx (broad spec) -> critical care may be necessary depending on presence or severity of shock & organ failure

  Sepsis 6 (if sepsis is suspected)

  Analgesia

  Correct electrolyte imbalances

  Biliary drainage/decompression

  • Endoscopic drainage -> potentially with stent placement for strictures
  • Percutaneous drainage (percutaneous transhepatic cholangiography)
  • Surgical drainage

  Management of underlying cause
• What are the possible complications of acute cholangitis?

  Acute pancreatitis

  Inadequate biliary drainage -> symptoms will recur or worsen

  Hepatic abscess
• Pathophys - acute cholangitis

  Obstruction within bile ducts -> stasis of bile (normally has antimicrobial properties) -> environment for bacterial growth -> bacteria from duodenum ascend through sphincter of Oddi into common bile duct -> inflammation & infection in biliary tree -> increased pressure within obstructed ducts -> translocation of bacteria & toxins into bloodstream -> bacteraemia & SIRS -> may lead to sepsis
• What are the common causative pathogens of acute cholangitis?

  E.coli

  Klebsiella

  Enterococcus