Cholangitis

Question 1

acute obstructive cholangitis

Answer 1

biliary obstruction causing:
lethargy or mental confusion 
shock
fever
jaundice
abdo pain

5 Sx are known as Reynold’s pentad

Question 2

cholangitis

Answer 2

infection of the bile duct
usually by bacteria ascending its junction with the duodenum or biliary stasis
most common: klebsiella, E. coli, enterobacter

Question 3

charcot’s triad

Answer 3

fever intermittent, accompanied by chills)
RUQ pain
jaundice

Question 4

infection of CBD

Answer 4

bile normally sterile
if CBD is obstructed, biliary stasis and infection can occur
infection can flow in a retrograde direction up the CBD as a result of acute cholecystitis or instrumentation (eg ERCP)

Question 5

epidemiology

Answer 5

9% admitted with gallstone disease have acute cholangitis
1% develop after ERCP
median age 50-60yo
male=female
malignant disease (bile duct, gallbladder, ampullary, pancreatic and duodenal tumours) accounts for 10-30% of cases with acute cholangitis

Question 6

aetiology

Answer 6

obstruction of gallbladder or bile duct due to stones
ERCP
local tumours
bile duct stricture/stenosis
choledochocele (cyst or diverticulum of CBD)
AIDS cholangiopathy
parasitic infection - roundworm, liver fluke

Question 7

presentation

Answer 7

50-70% present with charcot’s triad - fever, RUQ pain, jaundice
poorly localised abdo pain in the elderly
mild, moderate or severe
severe = acute cholangitis ass. w/ one of: CV, neuro, resp, renal, hepatic and/or haematological dysfunction
10-20% also present with hypotension (due to septic shock) and mental confusion - the Reynold’s pentad
acholic (putty coloured) stools
pruritus
Hx of gallstones, CBD stones, recent cholecystectomy, ERCP, HIV or AIDS

peritonism is an unusual sign, and should stimulate the search for an alternative diagnosis

Question 8

diagnostic criteria for acute cholangitis

Answer 8

A. systemic inflammation
A-1. fever and/or chills
A-2. lab results showing inflammation

B. cholestasis
B-1. jaundice
B-2. abnormal LFTs

C. imaging
C-1. biliary distension
C-2. evidence of aetiology on imaging (stricture, stone, stent etc.)

suspected = one item in A + one from B or C
definite = one item from A, B and C

Question 9

DDx

Answer 9

gallstones and cholecystitis
diverticular disease
hepatitis
mesenteric ischaemia
pancreatitis
other causes of septic shock
cirrhosis
liver failure
liver abscess
acute appendicitis
perforated peptic ulcer
pyelonephritis

Question 10

LFTs

Answer 10

AST/ALT = liver

alk phos = biliary