Makindo Medical Notes

Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain/Peritonitis |Assessing Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

Patients typically present with fever, jaundice, and right upper quadrant (RUQ) pain, known as Charcot's triad. Ascending cholangitis is a potentially life-threatening infection of the bile ducts that requires prompt diagnosis and treatment.

About

• Ascending cholangitis is a serious bacterial infection of the biliary tree.
• It involves inflammation and obstruction of the bile duct system.
• Common causes include stones in the common bile duct (CBD) or other obstructive factors.

Aetiology

• Gallstones: The most common cause, leading to bile duct obstruction and infection.
• Biliary strictures: Can occur post-surgery or from chronic inflammation.
• Tumors: Cholangiocarcinoma or pancreatic cancer can obstruct bile flow.
• Parasites: Liver flukes and other parasites can cause obstruction in endemic areas.

Microbiology

• Common Gram-negative bacteria: Escherichia coli, Klebsiella spp., Pseudomonas spp., and Enterobacter spp.
• Gram-positive bacteria: Enterococcus, Streptococcus, and Staphylococcus species.

Types

• Primary Sclerosing Cholangitis (PSC)
• Secondary (Acute) Cholangitis (focus of this topic)
• IgG4-Associated Cholangitis (IAC)

Causes

• Gallstones
• Benign and malignant strictures
• Primary Sclerosing Cholangitis (PSC)
• Chronic pancreatitis
• HIV-related cholangiopathy

Clinical Features

• Charcot's triad: Jaundice, RUQ pain, and fever/rigors.
• Reynolds' pentad: Jaundice, RUQ pain, fever/rigors plus confusion and hypotension (suggestive of sepsis).
• Biliary obstruction: Dark urine and pale stool.
• Hypotension: May indicate septic shock.
• Altered mental status: Confusion or lethargy, which may be a sign of sepsis.

Diagnostic Criteria

• Clinical Features:
  • 1. History of a biliary disorder
  • 2. Fever and/or chills
  • 3. Jaundice
  • 4. Abdominal pain
• Laboratory Features:
  • 5. Presence of inflammatory markers (elevated WCC and C-reactive protein)
  • 6. Elevated liver enzymes
• Imaging Findings:
  • 7. Evidence of biliary dilatation or other abnormalities indicating a hepatobiliary disorder
• Suspected Diagnosis: Requires two or more items from the clinical features list.
• Definite Diagnosis: Either Charcot's triad (criteria 2, 3, and 4) or two clinical features plus both laboratory and imaging findings.

Investigations

• FBC: Often shows raised WCC and CRP indicating infection and inflammation.
• LFTs: Usually raised ALP, GGT, and bilirubin.
• Blood Cultures: Helpful in identifying causative bacteria, especially in septic patients.
• Liver Ultrasound (USS): Used to detect stones and biliary duct dilation.
• Abdominal CT: Provides detailed images, helpful in identifying abscesses or other complications.
• ERCP (Endoscopic Retrograde Cholangiopancreatography): The gold standard for both diagnosis and treatment. It allows visualization, stenting, and sphincterotomy to remove obstructions.

Complications

• Sepsis and hypotension: May lead to multi-organ failure and mental status changes.
• Gallbladder empyema: Accumulation of infected fluid, potentially leading to abscess formation.
• Liver abscess: Localized pockets of infection in the liver can occur if cholangitis is untreated.
• Acute kidney injury: Often results from sepsis or dehydration.
• Biliary cirrhosis: Long-term obstruction and inflammation can cause liver scarring.

Management

• IV fluids and resuscitation following basic ABC protocols.
• Antibiotics: Initial broad-spectrum coverage with regimens such as Cephalosporin/Metronidazole or Amoxicillin and Gentamicin until culture results are available.
• ERCP with biliary drainage: Essential for obstructive cholangitis. A sphincterotomy may be performed to release stones and facilitate drainage.
• Malignancy Management: If a malignant stricture is present, a stent can be placed to maintain bile flow.
• Cholecystectomy: Recommended within 6-12 weeks for gallbladder stones, commonly performed laparoscopically.

References

• Cholangitis: Diagnosis, Treatment, and Prognosis