Acute Cholangitis

Background

Acute buliary infection -> systemic infectious disease-> prompt treatment -> significant mortality rate

The First report : Charcot’s 1877

“The Symptoms of Hepatic Fever”

Definition

• morbid condition with acute inflammation and infection in the bile duct

Acute Cholangitis:

• Abdominal Pain, Jaundice, Fever1877 : Hepatic Fever-> Trias

Charcot’s

• Charcot’s + << consciousness + Shock

1959: Acute Obstructive

Cholangitis -> Pentad Reynolds’s

Definition

• Longmire’s Classification:

• 1. Acute cholangitis developing from acute cholecystitis• 2. Acute non-suppurative cholangitis• 3. Acute suppurative cholangitis• 4. Acute obstructive suppurative cholangitis• 5. Acute suppurative cholangitis accompanied by

hepatic abscess

Etiology

• Billiary Obstruction: choledocholithiasis, benign billiary stenosis, stricture, stenosis (malignancy

• Bile Infection

Requires 2 factors:

Mirizzi syndrome

Lemmels sydrome

Etiology

Risk Factors• choledocholithiasis + Jaundice -> 90 %

consist bacteria• Patients with incomplete obstruction -

> higher postive bile culture than complete obstruction

Pathophysiology

• >> bacteria in the bile duct• >> intraductal pressure -> Cholangio-venous reflux ->

Hepatic Abscess , Sepsis

Pathophysiology

Diagnosis

Diagnosis – Clinical Presentation

• Clinical Presentation

• Cholangitis:• Charcot’s triad + Rigor• Pentad Reynolds’s (Grade III)

• Cholecystitis:• RUQ pain, nausea, vomit, Fever, palpable

gallbladder, Murphy’s sign (Se 79-96%)

Diagnosis - Blood Tests

•WBC• C-reactive Protein• Liver function test: Alk Phoshatase, GGT,

AST, ALT, Bilirubin

• Platelet, BUN, Creatinine, PT• Blood Culture• Amilase

Diagnosis - Imaging

• Imaging•Abdominal USG• CT with IV contrast

Diagnosis (Tokyo Guideline, 2013)

• Blood + Imaging + Charcot

Diagnosis (Tokyo Guideline, 2013)

Diagnosis (Tokyo Guideline, 2013)

Diagnosis (Tokyo Guideline, 2013)

Differential Diagnosis

• Acute Cholecytitis• Gastric and Duodenal • Ulcer• Acute Pancreatitis• Acute Hepatitis• Septicaemia from other origin

Management

Management - Antibiotic

Management

Management

Management

Management

ERCP

Transhepatic

Prognosis

• After 1980 : the death 10-30%• Major causes: MOF + irreversible shock , heart failure

and pneumonia

Thank You