GI: Ascending Cholangitis

Question 1

How does ascending cholangitis occur?

Answer 1

Bile outflow obstruction causes bile stasis and increased intraluminal pressure… allows bacterial colonisation and infection of the biliary tree.

Common causes of biliary tree occlusion:

• gallstone
• ERCP
• cholangiocarcinoma

Less common causes:

• pancreatitis
• primary sclerosing cholangitis
• ischaemic cholangiopathy
• parasitic infection

Question 2

Name the 3 most common infective organisms causing ascending cholangitis.

Answer 2

1. Escherichia coli (27%)
2. Klebsiella spp. (16%)
3. Enterococci (15%)

Question 3

Describe the common presentation of a pt with ascending cholangitis.

Answer 3

Charcot’s triad (50-70%):

• RUQ pain
• fever
• jaundice

Reynolds’ pentad (10-20%):

• hypotension (due to septic shock)
• mental confusion

Other possible signs/symptoms:

• pruritis (bile salt accumulation)
• rigors
• tachycardia

Question 4

What is the differential diagnosis for ascending cholangitis?

Answer 4

• Cholangitis (RUQ pain + fever without jaundice)
• Hepatitis, cirrhosis, liver failure, liver abscess
• mesenteric ischaemia
• pancreatitis

Question 5

Which investigations would you perform on a Pt with suspected ascending cholangitis?

Answer 5

1. Bloods
   - FBC: increased WCC due to infection
   - CRP: increased due to inflammation
   - LFTs: increased ALT, increased bilirubin +/- increased GGT - post hepatic jaundice features
   = UandEs: associated renal dysfunction
2. Imaging
   - ERCP (gold standard): both diagnostic and therapeutic
   - MRCP: 80-100% sensitivity for CBD stones
   - USS biliary tract: will show bile duct dilation (>6mm) and may show underlying cause (e.g. gallstones - 30% sensitivity)

Question 6

Describe how you would manage a Pt with ascending cholangitis.

Answer 6

ABCDE

1. Fluid resuscitation
2. IV antibiotics
3. ERCP - emergency endoscopic drainage/decompression

+/- laparascopic cholecystectomy (once infection resolved) - recommended for all pts fit for surgery with symptomatic gallstone disease

Question 7

What is the prognosis of ascending cholangitis?

Answer 7

Mortality rate 17-40% depending on comorbidities and age.

Early endoscopic drainage after Pt stabilisation significantly improves the prognosis.

Question 8

Suggest possible complications of ascending cholangitis.

Answer 8

1. liver abscesses, liver failure

2. bacteraemia and gram negative sepsis… septic shock, AKI and multi-organ failure