Acute Cholangitis

Question 1

Define Acute Cholangitis and summarise its aetiology and epidemiology

Answer 1

Definition: Infection of the bile duct

Aetiology/risk factors:
There are several causes-
- Obstruction of the gallbladder or the bile duct due to stones.
- ERCP
- Tumours e.g. pancreatic, cholangiocarcinoma.
- Parasitic infection (e.g. ascariasis.)

Epidemiology:

• 9% of patients with gallstone disease will have acute cholangitis.
• Equal in males and females
• Median age of presentation: 50-60 years
• More common in fair skinned people

Question 2

Describe the history/presenting symptoms of acute cholangitis

Answer 2

Most patients present with Charcot’s triad:

• RUQ pain
• Jaundice
• Fever with rigors

Can be extended to include Reynolds’ Pentad:

• Mental confusion
• Septic shock

Patients may also complain of pruritus (itching)

Question 3

What are the signs of acute cholangitis upon physical examination?

Answer 3

• Fever
• RUQ tenderness
• Mild hepatomegaly
• Jaundice
• Mental status changes
• Sepsis
• Hypotension
• Tachycardia
• Peritonitis (uncommon- check for alternative diagnosis)

Question 4

What investigations are used to identify acute cholangitis?

Answer 4

Bloods:

• FBC: High WCC
• CRP/ESR: possibly raised
• LFTs: typical pattern of obstructive jaundice (raised ALP + GGT)
• U&Es: May be sign of renal dysfunction.
• Blood cultures: check for sepsis.
• Amylase: May be raised if lower part of common bile duct is involved.

Imaging:

• X-ray KUB: look for stones
• Abdominal ultrasound: look for stones and dilation of the common bile duct.
• Contrast-enhanced CT/MRI: good for diagnosing cholangitis.
• MRCP: may be necessary to detect non-calcified stones.

Question 5

How is acute cholangitis managed?

Answer 5

• Resuscitation: may be required if in septic shock.
• Broad-spectrum antibiotics: given once blood cultures have been taken (select antibiotics that are effective against anaerobes and gram-negative organisms: e.g. cefuroxime + metronidazole).
• Most patients respond to antibiotics but endoscopic biliary drainage is usually required to treat the underlying obstruction.

Depends on severity :
- Stage 1 (Mild)- antimicrobial therapy, percutaneous, endoscopic or operative intervention for non-responders.

• Stage 2 (Moderate)- Early percutaneous or endoscopic drainage, endoscopic biliary drainage is recommended.
• Stage 3 (Severe)-
  (Note: Severe cholangitis counts as including shock, conscious disturbance, acute lung injury, AKI, hepatic injury or DIC.) Treatment of organ failure with ventilatory support, vasopressors etc. Urgent percutaneous or endoscopic drainage. Definitive treatment required once the clinical picture improves.

Question 6

What are the possible complications of acute cholangitis?

Answer 6

• 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 7

Summarise the prognosis for patients with acute cholangitis

Answer 7

Mortality between 17-40%