Ascending cholangitis
Background
- Also known as "acute cholangitis" or simply "cholangitis"
- Requires the presence of biliary obstruction and infected biliary tract
Anatomy & Pathophysiology
- Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
- These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
- Bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.
Gallbladder disease types
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Gallbladder anatomy (overview).
Gallbladder anatomy
Causes
- Choledocholithiasis
- Biliary tract stricture
- Compression by malignant disease
Clinical Features
- Charcot's Triad: Fever + jaundice + RUQ pain
- Occurs in ~50%
- Reynold's Pentad: The triad + altered mental status + hypotension
- Occurs in <5%
- Hypotension may be the only presenting sign in elderly patients
Differential Diagnosis
RUQ Pain
- Gallbladder disease
- Symptomatic cholelithiasis (biliary colic)
- Choledocholithiasis
- Acute cholecystitis
- Ascending cholangitis
- Acalculous cholecystitis
- Peptic ulcer disease with or without perforation
- Pancreatitis
- Acute hepatitis
- Pyelonephritis
- Pneumonia
- Kidney stone
- Pancreatitis
- GERD
- Appendicitis (retrocecal)
- Pyogenic liver abscess
- Fitz-Hugh-Curtis Syndrome
- Hepatomegaly due to CHF
- Herpes zoster
- Myocardial ischemia
- Bowel obstruction
- Pulmonary embolism
- Abdominal aortic aneurysm
Evaluation
MRCP image of two stones in the distal common bile duct
Duodenoscopy image of pus extruding from Ampulla of Vater, indicative of cholangitis.
Work-up
- Labs
- CBC: Leukocytosis with neutrophil predominance
- LFTs: Elevated alk phos and conjugated bilirubin
- GGT elevation much more sensitive than alk phos
- Blood cultures
- Imaging
- RUQ Ultrasound
- Dilatation of CBD ( > 6mm) and presence of choledocholithiasis
- May miss small CBD stones and in acute cases CBD may not have had time to dilate
- RUQ Ultrasound
- ERCP
- Should be obtained to confirm the diagnosis and for possible intervention
Management
- Aggressive sepsis resuscitation
Antibiotics
Coverage is targeted at E. coli, Enterococcus, Bacteroides, and Clostridium (anerobic)
- Metronidazole 500mg IV q8hrs PLUS Ciprofloxacin 400mg IV q12hrs
- Piperacillin/Tazobactam 4.5g IV q8hrs
- Imipenem/Cilastin 500mg IV q6hrs
- Doripenem 500mg IV q8hrs
- Meropenem 1g IV q8hrs
- expand coverage for MRSA if severe sepsis or septic shock
- Vancomycin 15-20mg/kg PLUS any of the following options
Consultation
- Involvement with GI for ERCP and general surgery for acute cholecystectomy is necessary for source control and biliary decompression
Disposition
- Admit
See Also
- Gallbladder Disease (Main)
References
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