Acute cholangitis

Question 1

define acute cholangitis?

Answer 1

infection of the bile duct

Question 2

outline the aetiology/ risk factors of acute cholangitis?

Answer 2

obstruction of gallbladder or bile duct due to stones

ERCP

Tumours ( pancreatic, cholangiocarcinoma)

bile duct structure or stenosis

parasitic infection ( ascariasis)

Question 3

summarise the epidemiology of acute cholangitis?

Answer 3

• 9% of patients admitted to hospital with gallstone disease will have acute cholangitis
• Equal in males and females
• Median age of presentation: 50-60 yrs

Racial distribution follows that of gallstone disease - fair-skinned people

Question 4

what is charcot’s triad?

Answer 4

right upper quadrant pain- may refer to right shoulder

jaundice

fever with rigors

Question 5

what is reynold’s pentad?

Answer 5

mental confusion

septic shock- hypotension

Question 6

what are the presenting symptoms of acute cholangitis?

Answer 6

charcot’s symptoms

• right upper quadrants- may refer to right shoulder
• jaundice
• fever with rigors

Reynolds’ Pentad

• mental confusion
• septic shock- hypotension
• patients may also complain of pruritus
• stool colour is putty/ clay

Question 7

what are the signs of acute cholangitis on physical examination?

Answer 7

fever

RUQ tenderness

Murphy’s sign positive

Mild hepatomegaly

Jaundice

Mental Status changes

Sepsis

Hypotension

Tachycardia

Question 8

what are the investigations for acute cholangitis?

Answer 8

bloods

ERCP

Abdominal ultrasound- look for stones and dilation of the common bile duct

Contrast- enhanced- good for diagnosing cholangitis but not for detecting gall stones

MRCP- may be necessary to detect non-calcified stones-> when ultrasound

Question 9

describe blood results for acute cholangitis?

Answer 9

○ FBC: High WCC, low plts
○ CRP/ESR: possibly raised
○ LFTs: typical pattern of obstructive jaundice (raised ALP + GGT)
○ U&Es: may be signs of renal dysfunction
○ Blood cultures: check for sepsis
○ Amylase: may be raised if the lower part of the common bile duct is involved
○ In severe cases low bicarbonate and met acidosis
PTT may be raised with sepsis

Question 10

what are the possible complications of acute cholangitis?

Answer 10

• Liver abscesses
• Liver failure
• Bacteraemia
• Gram-negative sepsis
• Septic shock
• AKI
• Organ dysfunction

• Percutaneous or endoscopic drainage can lead to:
Intra-abdominal or percutaneous bleeding, sepsis, fistulae and bile leakage

Question 11

summarise the prognosis for patients with acute cholangitis?

Answer 11

mortality between 17-40%

Question 12

Outline a management plan for acute cholangitis?

Answer 12

• ABC
• IV antibiotics: given once blood cultures have been taken
○ Piperacillin + tazobactam
OR
○ Imipenem + cilastatin
OR
○ Cefepime + metronidazole
• Resuscitation: may be required if the patient is in septic shock – sepsis 6
• May need opioid analgesics
• Most patients respond to antibiotics but endoscopic biliary drainage is usually required to treat the underlying obstruction
○ ERCP
○ Lithotripsy (US shock waves) if bile duct stones are large or difficult to remove
Last line: choledectomy with T-tube places or cholecystectomy