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

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

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)