Acute cholangitis

Question 1

What is acute cholangitis?

Other names for it?

Answer 1

Infection of the biliary tree (which can include bile duct etc) due to obstruction i.e. obstruction of bile duct.

AKA; ascending cholangitis (old), cholangitis.

Question 2

Explain the aetiology / risk factors of acute cholangitis

Answer 2

Several causes:

1. Obstruction of the gallbladder or bile duct due to stones

ERCP - Endoscopic retrograde cholangio-pancreatography, a diagnostic procedure

Tumours (e.g. pancreatic, cholangiocarcinoma)

Bile duct stricture or stenosis

5. Parasitic infection (e.g. 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

Recognise the presenting symptoms of acute cholangitis

Answer 4

• Most patents present with Charcot’s Triad of symptoms:
○ RUQ Pain
○ Jaundice
○ Fever with rigors

• This list of symptoms has been extended to include the following two symptoms, forming the Reynolds’
Pentad (infectoin leading to pus in bile duct):

○ Confusion
○ Signs of Septic shock
• Patients may also complain of pruritus

Question 5

Signs of shock?

Answer 5

Low BP
High or Low body temp

High RR
High HR

Acutely altered mental state
Signs associated with specific source of infection.

And more.

Question 6

Recognise the signs of acute cholangitis on physical examination

Answer 6

• Fever
• RUQ tenderness
• Mild hepatomegaly
• Jaundice
• Mental status changes

later
• Sepsis
• Hypotension
• Tachycardia
• Peritonitis (uncommon - check for alternative diagnosis)

Question 7

Identify appropriate investigations for acute cholangitis

Answer 7

The following are 1st line;
• Bloods
○ = FBC: High WCC

○ CRP/ESR: possibly raised

○ LFTs: typical pattern of obstructive jaundice (raised ALP + GGT) hyperbilirubinaemia, raised serum transaminases.

○ U&Es: may be signs of renal dysfunction

○ Blood cultures: check for sepsis - usually gram negatives present

○ Amylase: may be raised if the lower part of the common bile duct is involved

ABGs ; metabolic acidosis.

Others;
Imaging
○ ERCP - bile duct stone or other obstruction
○ Abdominal ultrasound: dilated bile duct. common bile duct stones.

consider:
○ Contrast-enhanced CT/MRI: good for diagnosing cholangitis
○ MRCP: may be necessary to detect non-calcified stones

Question 8

Generate a management plan for acute cholangitis

Answer 8

1st line;
IV Abx and intensive medical management;
Metronidazole + Ciprofloxacin (or gentamicin) IV
- drugs targetting gram negative anaerobes& oragnisms)

Plus;
ERCP with or without sphincterotomy and;
placement of drainage stent

OR

percutaneous trans-hepatic cholangiography (PTC)

• used to place stents when ercp unsuccesful.
• contraindicated; biliary tract sepsis

Because;
Most patients respond to antibiotics but endoscopic biliary drainage is usually required to treat the underlying obstruction .

ercp - removes bile stones, places stents, dilation of strictures

Question 9

Identify the possible complications of acute cholangitis

Answer 9

3 main ones;
Liver abscesses

Acute pancreatitis

Gram-negative sepsis

Others;
Liver failure  
Bacteraemia  
Septic shock  
AKI  
Organ dysfunction  
Percutaneous or endoscopic drainage can lead to: 
Intra-abdominal or percutaneous bleeding,fistulae and bile leakage