Gastro Flashcards
Acute Cholangitis - Definition & Presentation
Acute Cholangitis is an infection of the biliary tree that requires fast diagnosis and treatment.
Presents with:
-diffuse RUQ Pain
-Fever
-Jaundice
(Charcot’s Triad)
!!NEGATIVE MURPHY’S SIGN!!
If left untreated can cause Sepsis which is life threatening
Other presentations:
-Pale stool (from lack of bile secretion)
-Pruritus (linked with any disease affecting the Liver)
In more extreme cases:
-Hypotension
-Altered mental status
Acute Cholangitis - Aetiology & Risk Factors
Generally caused by biliary obstruction
Most common cause: Cholelithiasis (Gallstones) –> Choledocholithiasis (Common bile duct stones)
Sclerosing cholangitis = 24% of acute cholangitis
Can also be caused by strictures from surgical injury, chronic pancreatitis (stricture of common bile duct), benign tumours
Malignant stricture = less likely
Risk Factors:
-age >50
-Cholelithiasis
-existing benign stricture
-malignant stricture
-hx of primary/secondary sclerosing cholangitis
Acute Cholangitis - Epidemiology
Relatively uncommon - complication of <10% for those admitted with cholelithiasis
More common in the elderly - average age range = 50 to 60
Look for PMHx of surgeries around the liver/bile ducts/pancreas/Galbladder
Acute Cholangitis - Differentials
1) Acute cholecystitis –> Positive Murphy’s sign (Pain on palpation of RUQ and inspiration: hitched breath)
2) Peptic ulcer disease –> Symptoms improve with food and antacids
3) Acute Pancreatitis –> Hx of alcohol consumption or medication-induced chronic pancreatitis. Pain is often more severe than in Acute Cholangitis
4) Hepatic abscess (can be seen alongside Acute Cholangitis) –> Hepatomegaly, acute abdomen (sudden onset of severe abdominal pain)
5) Acute pyelonephritis –> Flank pain, costovertebral angle tenderness
6) Acute appendicitis –> McBurney’s point tenderness, obturator sign (pain with passive flexion and internal rotation of the right hip), acute abdomen w/ rebound, guarding
7) Right lower lobe pneumonia –> Positive Hx of cough w/ SOB. Crackles on lung auscultation
Acute Cholangitis - Investigations
Order on Admission:
-FBC –> lowered platelets, increased WBCs
-Serum Urea –> raised when severe
-Serum Creatinine –> raised when severe
-Serum LFTs –> hyperbilirubinemia, raised serum transaminases & alkaline phosphatase
-CRP –> raised
-Serum Potassium –> normal/decreased
-Serum Magnesium –> normal/decreased
-Blood Cultures –> bacteria are usually gram negative, but can be associated with gram-positive and anaerobic bacteria
Order on Admission if Sepsis is suspected:
-Coagulation Panel –> raised prothrombin time in sepsis
-ABG Analysis –> in severe cases metabolic acidosis (low bicarbonate and raised anion gap), raised lactate
Order for all patients with RUQ pain and suspected cholangitis:
-Transabdominal Ultrasound –> dilated bile duct, common bile duct stones
Acute Cholangitis - Management
First line is give intravenous broad-spec antibiotics
–>piperacillin/tazobactam: 4.5 g intravenously every 8 hours, may increase to 4.5 g every 6 hours in severe infections
Stabilise haemodynamic factors as needed –> often need bolus intravenous fluids
Urgent biliary decompression within 24 hrs –> ERCP, drainage stent, stone extraction
consider:
- Opioid analgesic + paracetamol for pain management
–> paracetamol: 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day; 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
–> morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response
– AND –
If progression into Sepsis then Sepsis Six
Once stable switch to targeted antibiotics, monitor
Surgery as last resort
Acute Cholangitis - Prognosis & Complications
If adequate biliary drainage is achieved within 24 hrs and all sepsis has been avoided, prognosis is good
If there is an underlying medical condition or decompression is delayed prognosis is poorer.
Predicters of poor prognosis:
-hyperbilirubinemia
-high fever
-leucocytosis -older age
-renal dysfunction
-hypoalbuminemia
-those requiring emergency surgery
Possible Complications:
- Acute Pancreatitis = medium chance
–> distal choledocholithiasis can also cause obstructions of the pancreatic duct
–>It can also be a complication of ERCP (Endoscopic Retrograde Cholangiopancreatography
-Hepatic Abscess = low chance
-Inadequate biliary drainage following endoscopy/radiology/surgery = low chance
–> symptoms will persist/worsen
Acute Cholecystitis - Definition & Presentation
Acute cholecystitis is inflammation of the gallbladder and a major complication of cholelithiasis
Presentations:
- RUQ pain and localised tenderness, with or without guarding
- symptomatic gallstones are common before developing cholecystitis
- fever/chills
- Nausea
- Right shoulder pain
- Anorexia
- Can get jaundice
Acute Cholecystitis - Aetiology & Risk Factors
At least 90% of patients have gallstones
Starvation, total parenteral nutrition, narcotic analgesics, and immobility are predisposing factors for acute acalculous cholecystitis (w/out gallstones)
Infection w/ Helminth or Salmonella can also cause it
Fixed obstruction or passage of gallstones into the gallbladder neck or cystic duct causes acute inflammation of the gallbladder wall. impacted gallstone causes bile to become trapped in the gallbladder, which causes irritation and increases pressure in the gallbladder causing the inflammatory response
Risk Factors:
- Gallstones
- Severe illness
- Total parenteral nutrition (TPN)
- Diabetes
Acute Cholecystitis - Differentials
1) Acute cholangitis
-> presents with jaundice, fever, chills, and abdominal pain
2) Chronic cholecystitis
-> Repeated bouts of mild attacks or chronic irritation by large gallstones
3) Peptic ulcer disease
-> Burning epigastric pain that occurs hours after meals or with hunger
-> Often wakes the patient at night
-> Pain improves with eating
4) Acute pancreatitis
-> Epigastric or periumbilical abdominal pain that radiates to the back
-> Tripling of serum amylase and lipase
5) Sickle cell crises
-> Hx of Sickle cell
-> Associated w/ gallstones
-> Pain can occur anywhere in the body
Acute Cholecystitis - Investigations
1) CT or MRI of the abdomen -> If Sepsis is suspected
-> Irregular thickening of gallbladder wall
-> gas in gallbladder lumen/wall
-> Poor contrast enhancement of the gallbladder wall
2) Abdominal ultrasound -> If Sepsis not suspected
-> Distended gallbladder
-> Thickened gallbladder wall (>3 mm)
-> Gallstones
-> Pericholecystic fluid
3) FBC -> WBC increased for infection/inflammation
4) CRP -> High = inflammation
5) Bilirubin -> High
6) LFTs
7) serum lipase or amylase -> Identify or exclude the presence of acute pancreatitis
8) blood cultures and/or bile cultures -> Request if Sepsis to check for the cause
Acute Cholecystitis - Management
1) Treat for Sepsis if applicable
+ Analgesia as pain is the predominant symptom
-> Paracetamol: 500-1000 mg orally every 4-6 hours when required
2) Remove cholelithiasis and gallbladder
3) Discharge -> Advise patients that they do not need to avoid any particular food or drinks after having their gallbladder or gallstones removed, but to seek further advice from their general practitioner if eating or drinking causes new symptoms to develop
Acute Cholecystitis - Prognosis & Complications
Removing the gallbladder and the contained gallstones when biliary pain starts will prevent further biliary attacks and reduce the risk of developing cholecystitis. If the gallbladder perforates, mortality is 30%
Untreated acute acalculous cholecystitis is life-threatening and is associated with up to 50% mortality
Without treatment, acute cholecystitis may resolve spontaneously within 1–7 days. However, 25–30% of people will require surgery or develop complications:
1) Necrosis of the gallbladder wall
2) Perforation of the gallbladder
3) Biliary peritonitis
4) Pericholecystic abscess
5) Fistula (between the gallbladder and duodenum) -> caused by a large gallbladder stone eroding through the wall of the gallbladder
6) Jaundice
