Cholangitis Flashcards

1
Q

Define cholangitis

A

Infection and inflammation of the biliary tree, most commonly caused by obstruction

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2
Q

Aetiology of cholangitis

A

Ascending cholangitis is a bacterial infection (typically E. coli) of the biliary tree. The most common predisposing factor is gallstones.

  • Cholelithiasis -> choledocholithiasis and biliary obstruction
  • Iatrogenic biliary duct injury (commonly via surgical injury during cholecystectomy) -> benign strictures
  • 1-3% of patients develop cholangitis after ERCP
  • Sclerosing cholangitis (primary and secondary) - 24% of cases
  • Chronic pancreatitis + stenosis and stricture of the distal common bile duct
  • Radiation-induced biliary injury
  • Biliary injury as a complication of systemic chemotherapy
    Obstruction of the common bile duct -> liver pathology
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3
Q

Symptoms of cholangitis

A

Charcot’s triad
- Right upper quadrant pai
- Jaundice
- Fever

  • Right upper quadrant tenderness
  • Pruritus
  • Mental status changes
  • Pale stools

Reynold’s = +hypotension, confusion

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4
Q

Signs of cholangitis on examination

A

General/obs:
- Hypotension
- Fever
- Jaundice
- Mental status changes

Abdo:
- Right upper quadrant tenderness

PR:
- Pale stools

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5
Q

Investigations for cholangitis

A

LFTs: hyperbilirubinaemia, raised ALT/AST, ALP
FBC: raised WCC, thrombocytopenia
ABG/VBG: metabolic acidosis, raised lactate
CRP: raised
U&Es: K+/Mg reduced
Renal screen: severe → U and Cr raised
Blood cultures: ?bacteraemia
Clotting: raised PTT

Abdo US: ?dilated bile ducts, common bile duct stones
ERCP: stone/obstruction seen
MRCP: mass impinging on biliary tree, stricture, and/or choledocholithiasis (If ERCP and USS cannot confirm presence of gallstones)

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6
Q

Management for cholangitis

A

Sepsis 6
1. Blood cultures
2. IV Abx e.g. piperacillin IV
3. IV fluids + correct electrolyte imbalances + clotting abnormalities
4. urine output, oxygen, lactate
+ Analgesia

→ biliary decompression with ERCP + drainage stent (24-48hrs)
- Or percutaneous trans-hepatic cholangiography
- Consider endoscopic lithotripsy
- Surgery: choledochotomy with T tube placement or cholecystectomy with bile duct exploration

Ongoing, non-emergency - elective surgery cholecystectomy if cholelithiasis is present

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7
Q

Prognosis of cholangitis

A

Rapid improvement once adequate biliary drainage is achieved, with improvement in haemodynamic parameters with significant inflammatory response parameters
Patients with significant underlying medical conditions + those who have delay in decompression have poorer prognosis
Poor prognosis: hyperbilirubinaemia | high fever | leucocytosis | older age

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8
Q

Complications of cholangitis

A

Acute pancreatitis
- Via obstruction of the pancreatic duct or the common channel joining common bile duct and pancreatic duct
- Also complication of ERCP
Inadequate biliary drainage following endoscopy, radiology or surgery
Hepatic abscess

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