Acute Cholangitis - SUNY Downstate Medical Center · • Presently tolerating diet, awaiting...

Acute Cholangitis

Prasanth Patcha, MD 24 April 2014

www.downstatesurgery.org

Case

87F hx of hypothyroid, dementia sent from SNF to ED for AMS and fever; Called by ED for hypotension, LFT’s; PSH: sigmoidectomy, end colostomy (volvulus) Multiple PEG tubes 103.4 77/44 104


Case

3/31 17:31h cbc 6.19 / 15 / 46 / 243 82% bmp 140 / 4.9 / 101 / 20 / 17 / 1.48 / 88 lft 7.2 / 3.8 / 183 / 197 / 584 / 6.6 (Db 4.6) LA 5.4


Case

4/1/14 0240h CBC 22.9 / 11.8 / 36 / 236 79% BMP 141 / 3.7 / 111 / 16 / 18 / 1.82 / 107 LFT 5.5/ 2.9 / 123 / 144 / 382 / 4.9 ABG 7.29 / 36 / 199 / 98 / 17 / -8.0


Case

• Intubated overnight in SICU for AMS

• Pressor therapy by AM

• Emergent ERCP – sphincterotomy – stent placed – stones extracted


Case

• Immediate improvement

• Weaned from pressors

• Extubated several days later

• Presently tolerating diet, awaiting discharge planning


Acute Cholangitis

• Ascending infection / inflammation of the

biliary tree

• Extremely rapid deterioration


Utoronto Perioperative Interactive Education http://pie.med.utoronto.ca/VLiver/index.htm


Epidemiology

• Median age 50 – 60

• Obstruction

– secondary choledocholithiasis (most common) – primary choledocholithiasis (Asians) – proximal obstruction


Pathophysiology

• Despite communication – bile usu sterile

• Bacterial overgrowth leads to increase in pressure – lymphatic/venous congestion – bacterial dissemination


Pathophysiology

• Instrumentation largely implicated

– stents – drains – strictures – ERCP – 0.5 to 1.7% of cholangitis


Pathophysiology

G- E coli Klebsiella Enterobacter G+ Enterococcus An Bacteroides Clostridium


Presentation

• Charcot’s Triad – fever – jaundice – RUQ pain

• Reynold’s Pentad – AMS – hypotension

<50%


Diagnosis

• Clinical Dx using radiography and lab values as supportive

• Need high suspicion in elderly or immunocompromised

• Or especially those with known biliary issues


TG13 www.downstatesurgery.org

TG13 Severity


Tokyo LOL www.downstatesurgery.org

Treatment

• Resuscitation

• BCx Then abx;

• EARLY DRAINAGE from below, or above


Treatment

• ERCP

• PTC

• If fail then OR – 40% mortality – Place T-tube and run


References Cameron, et al. Current Surgical Therapy. Sabiston. Textbook of General Surgery. Mayumi, T, et al. Tokyo Guidelines 2013.


Acute Cholangitis - SUNY Downstate Medical Center · • Presently tolerating diet, awaiting...

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