Ascending cholangitis: Difference between revisions
Ostermayer (talk | contribs) |
ClaireLewis (talk | contribs) No edit summary |
||
(One intermediate revision by one other user not shown) | |||
Line 7: | Line 7: | ||
===Causes=== | ===Causes=== | ||
*Choledocholithiasis | *[[Choledocholithiasis]] | ||
*Biliary tract stricture | *Biliary tract stricture | ||
*Compression by malignant disease | *Compression by malignant disease | ||
Line 25: | Line 25: | ||
===Work-up=== | ===Work-up=== | ||
*Labs | *Labs | ||
**Leukocytosis with neutrophil predominance | **CBC: [[Leukocytosis]] with neutrophil predominance | ||
**Elevated alk phos and conjugated bilirubin | **[[LFTs]]: Elevated alk phos and conjugated bilirubin | ||
**GGT elevation much more sensitive than alk phos | |||
**Blood cultures | **Blood cultures | ||
*Imaging | *Imaging | ||
Line 37: | Line 38: | ||
==Management== | ==Management== | ||
*Aggressive [[sepsis]] resuscitation | *Aggressive [[sepsis]] resuscitation | ||
===Antibiotics=== | ===Antibiotics=== | ||
{{Cholangitis antibiotics}} | {{Cholangitis antibiotics}} | ||
===Consultation=== | ===Consultation=== | ||
Involvement with GI for ERCP and general surgery for acute cholecystectomy is necessary for source control and biliary decompression | *Involvement with GI for ERCP and general surgery for acute cholecystectomy is necessary for source control and biliary decompression | ||
==Disposition== | ==Disposition== |
Revision as of 19:47, 29 September 2019
Background
- Also known as "ascending 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
- Symptomatic cholelithiasis (biliary colic)
- Choledocholithiasis
- Acute calculous cholecystitis
- Ascending cholangitis
- Acalculous cholecystitis
- Biliary atresia
- Cholestasis of pregnancy
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
- Pancreatitis
- Acute hepatitis
- Pancreatitis
- GERD
- Appendicitis (retrocecal)
- Pyogenic liver abscess
- Bowel obstruction
- Cirrhosis
- Budd-Chiari syndrome
- GU
- Other
- Hepatomegaly due to CHF
- Peptic ulcer disease with or without perforation
- Pneumonia
- Herpes zoster
- Myocardial ischemia
- Pulmonary embolism
- Abdominal aortic aneurysm
Evaluation
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