Cholangitis Flashcards
Define cholangitis
Infection and inflammation of the biliary tree, most commonly caused by obstruction
Aetiology of cholangitis
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
Symptoms of cholangitis
Charcot’s triad
- Right upper quadrant pai
- Jaundice
- Fever
- Right upper quadrant tenderness
- Pruritus
- Mental status changes
- Pale stools
Reynold’s = +hypotension, confusion
Signs of cholangitis on examination
General/obs:
- Hypotension
- Fever
- Jaundice
- Mental status changes
Abdo:
- Right upper quadrant tenderness
PR:
- Pale stools
Investigations for cholangitis
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)
Management for cholangitis
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
Prognosis of cholangitis
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
Complications of cholangitis
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