Acute Cholangitis Flashcards
Define acute cholangitis.
Acute cholangitis is a bacterial infection superimposed on an obstruction of the biliary tree most commonly from a gallstone, but it may be associated with neoplasm or stricture.
What is Reynolds’ pentad?
Acute obstructive cholangitis pentad:
- lethargy or mental confusion
- shock,
- fever,
- jaundice,
- abdominal pain
Occurs in more severe, life-threatening forms of cholangitis.
What is Charcot’s triad?
- RUQ pain,
- fever
- jaundice
50-70% of patients present with these symptoms
What is the epidemiology of acute cholangitis?
- Occurs in 1% of patients with cholelithiasis (gall stone formation)
- M=F
- Usually presents at age 50-60yrs
Occurs in 1-3% of patients post endoscopic retrograde cholangiopancreatography due to inadequate steps taken to ensure biliary drainage.
List some causes of acute cholangitis.
NB: ascending cholangitis is a historical term for acute cholangitis.
Most commonly:
- Cholelithiasis (gallstone formation) leads to choledocholithiasis (gallstones in bile duct) and biliary obstruction.
Other causes:
- Iatrogenic biliary duct injury
- Chronic pancreatitis
- Radiation-induced/chemotherapy-induced biliary injury
- Sclerosing cholangitis
- Parasite entry into bile ducts (Ascaris lumbricoides or Fasciola hepatica)
- Malignancy
Which organisms most commonly cause cholangitis?
The most common organisms isolated in bile are:
- Escherichia coli (27%),
- Klebsiella species (16%),
- Enterococcus species (15%),
- Streptococcus species (8%),
- Enterobacter species (7%),
- Pseudomonas aeruginosa (7%).
Describe the pathogenesis of acute cholangitis.
The main factors in the pathogenesis of acute cholangitis are
- biliary tract obstruction - diminishes host antibacterial defences, causes immune dysfunction, and subsequently increases small bowel bacterial colonization
- elevated intraluminal pressure - pushes the infection into the biliary canaliculi, hepatic veins, and perihepatic lymphatics → bacteraemia
- infection of bile
What are the risk factors for acute cholangitis?
- Age >50yrs
- Cholelithiasis
- Benign stricture
- Malignant stricture
- Post-procedure injury of bile ducts
- History of sclerosing cholangitis
How does acute cholangitis present?
- RUQ pain/upper abdominal pain
- Jaundice - 60-70%
- Fever - 90%
- Acholic stools (putty/clay stools due to deficient bile secretion to the small intestine)
- Pruritus (sensation of itch associated with any liver disease)
What are the investigations for acute cholangitis?
Diagnosis:
- Think “Could this be sepsis?” and treat within 1hr
- Transabdominal USS - order urgently if patient is high risk of sepsis
- +/- CT contrast - if USS inconclusive
- FBC
- U&Es
- Coagulation profile
- CRP
- LFTs
- Blood culture & ABG
Other:
- MRCP - if CT and US is negative
- ERCP (endoscopic retrograde cholangiopancreatography) - although this is usually reserved as the treatment once diagnosis made
- Surgery - laparotomy with common bile duct exploration (if all else fails)
Describe the blood test results in acute cholangitis.
- FBC - raised WBC
- CRP - elevated
- LFTs - hyperalbuminaemia is present but if absent then cholangitis is less likely, raised ALP and ALT
- Decreases in serum potassium and magnesium
- Blood culture - positive in 21-71%
- Coagulation - may have decreased platelets and raised prothrombin time.
- ABG - metabolic acidosis in severe disease
How do you treat acute cholangitis?
- ABCDE
- NBM
- Iv fluids
- Analgesia - opioids and paracetamol
- Broad-spectrum IV antibiotics e.g. piperacillin/tazobactam or cefuroxime/metronidazole - usually gram-negative, but gram +ve bacteria and anaerobes also implicated in cholangitis
- Biliary decompression - ERCP usually within 48hours or within 12hours for emergencies. Alternatively percutaneous trans-hepatic cholangiography (PTC).
- +/- Lithotripsy - stone fragmentation if bile duct stones too large to remove in ERCP
Once recovered: elective cholecystectomy.
What are the complications of acute cholangitis?
- Acute Pancreatitis - commonly caused by gallstones due to obstruction of the pancreatic duct leading
- Hepatic abscess - more common in PSC
- Gallstone Ileus - gallbladder and ileum may form a fistula allowing the gallstone to erode into the small bowel. If large enough (>2.5cm diameter) the gallstone becomes trapped leading to small bowel obstruction
What does GET SMASHED stand for?
What is the prognosis for patients with acute cholangitis?
Most patients experience rapid clinical improvement once adequate biliary drainage is achieved, with improvement in haemodynamic parameters and systemic inflammatory response parameters.
