Ascending cholangitis

Background

• Also known as "acute cholangitis" or simply "cholangitis"
• Requires the presence of biliary obstruction and infected biliary tract
  • Biliary obstruction leads to cholestasis, leading to bacterial ascent from duodenum
  • Bacteria can enter systemic circulation via hepatic sinusoids and lead to septic picture; this can occur rapidly

<translate>

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.

</translate>

Gallbladder disease types

Gallbladder anatomy (overview).

Gallbladder anatomy

Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.

• Symptomatic cholelithiasis (biliary colic)
• Choledocholithiasis
• Acute calculous cholecystitis
• Ascending cholangitis
• Acalculous cholecystitis
• Biliary atresia
• Cholestasis of pregnancy

Causes

• Choledocholithiasis
• Biliary tract stricture
  • Congenital strictures, or due to past biliary instrumentation, or due to Primary sclerosing cholangitis
• Compression by malignant disease
  • Most commonly pancreatic head cancer or cholangiocarcinoma
• Less commonly, parasitic obstruction from Ascaris spp or Clonorchis spp may lead to cholangitis

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 or Altered mental status 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
• Pancreatitis
• Acute hepatitis
• Pancreatitis
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Bowel obstruction
• Cirrhosis
• Budd-Chiari syndrome
• GU
  • Pyelonephritis
  • Kidney stone
  • Fitz-Hugh-Curtis Syndrome
• Other
  • Hepatomegaly due to CHF
  • Peptic ulcer disease with or without perforation
  • Pneumonia
  • Herpes zoster
  • Myocardial ischemia
  • 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.

• Tokyo Guidelines for Acute Cholangitis 2018 (See MDCalc)
  • Criteria is based on signs/labs and can fit "suspected diagnosis" or "definite diagnosis"
  • Grading can guide surgical/endoscopic management

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
• 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, sphincterotomy, and/or stenting

Disposition

• Admit

See Also

• Gallbladder Disease (Main)