Acute Cholangitis

Acute Cholangitis• Bacterial infection superimposed

on an obstruction of the biliary tree most commonly from a gallstone.

• May be associated with neoplasm or stricture.

Pathophysiology• A scending bacterial infection associat

ion with partial or complete obstructi on of bile ducts.

• Hepatic bile is sterile, bile in the bile d ucts is kept sterile by continuous bile f

low and by the presence of antibacteri al substances in bile such as immunog

lobulin.• Mechanical hindrance to bile flow facil

itates bacterial contamination.

Pathophysiology• T he combination of both significant ba

cterial contamination and biliary obstr uction is required for its development.

• Gallstones are the most common cause of obstruction in cholangitis.

• O ther causes are benign and malignan t strictures, parasites, instrumentatio n of the ducts and indwelling stents, a

- nd partially obstructed biliary enteric anastomosis.

Pathophysiology• The most common organisms cult

ured from bile in patients with ch olangitis include Escherichia coli,

Klebsiella pneumoniae, Streptoco ccus faecalis , and Bacteroides fra

gilis .

Clinical Presentation

• Cholangitis may present as anythi ng from a mild, intermittent, and

- self limited disease to a fulminant - , potentially life threatening septi

cemia.• -The patient with gallstone induce

d cholangitis is typically older an d female.

Clinical Presentation

• The most common presentation is fever , epigastric or right upper quadrant pai

n, and jaundice.• Charcot's triad are present in about tw

o thirds of patients.• P rogress rapidly with septicemia and di

sorientation, known as Reynolds pentad.

• Mild hepatomegaly • Peritonitis (uncommon)

Clinical Presentation

• History of the following increases the risk of cholangitis: – Gallstones, CBD stones – Recent cholecystectomy – Endoscopic manipulation or ERCP,

cholangiogram – History of cholangitis

• History of HIV or AIDS: AIDS-related cholangitis is characterized by extrahepatic biliary edema, ulceration, and obstruction.

Differential Diagnosis

• Cholecystitis• Diverticular disease• Hepatitis• Mesenteric ischemia • Pancreatitis

Work Up• CBC: Leukocytosis • liver function test : hyperbilirubinemia, e

levation of alkaline phosphatase and transaminitis are common

• PT PTT : Do not expect to be elevated unless sepsis is associated with disseminated intravascular coagulation or underlying cirrhosis exists.

• C-reactive protein level and erythrocyte sedimentation rate are typically elevated.

Work Up Imaging studies are important to

confirm the presence and cause of biliary obstruction and to rule out other conditions.

Transabdominal ultrasonography is the initial imaging study of choice. excellent for gallstones and cholecystitis.

• It is highly sensitive and specific for examining the gallbladder and assessing bile duct dilatation.

InvestigationAdvantages to sonography include the ability to be performed rapidly at the bedside by the ED physician, capacity to image other structures (eg, aorta, pancreas, liver), identification of complications (eg, perforation, empyema, abscess), and lack of radiation.

Investigation– Disadvantages to sonography

include operator and patient dependence, cannot image the cystic duct, and decreased sensitivity for distal CBD stones.

– A normal sonogram does not rule out acute cholangitis.

Investigation• The definitive diagnostic test is ERC.• In cases in which ERC is not available,

PTC is indicated.• Both ERC and PTC will show the level

and the reason for the obstruction, al low culture of the bile, possibly allow the removal of stones if present, and

drainage of the bile ducts with drainage catheters or stents.

Investigation Endoscopic retrograde

cholangiopancreatography (ERCP) is both diagnostic and therapeutic and is considered the criterion standard for imaging the biliary system. oERCP has a high success rate (98%)

and is considered safer than surgical and percutaneous intervention.

oComplications include pancreatitis, bleeding, and perforation.

Investigation• CT scanning and MRI will show

pancreatic and periampullary masses, if present, in addition to the ductal dilatation.

• Gallstones are poorly visualized with traditional CT scan.

Investigation Magnetic resonance

cholangiopancreatography (MRCP) is a noninvasive imaging modality that is increasingly being used in the diagnosis of biliary stones and other biliary pathology.

Investigation– MRCP is accurate for detecting

choledocholithiasis, neoplasms, strictures, and dilations within the biliary system.

– Limitations of MRCP include the inability for invasive diagnostic tests such as bile sampling, cytologic testing, stone removal, or stenting.

– It has limited sensitivity for small stones

(<6 mm in diameter).

Investigation– HIDA and DISIDA scans are functional

studies of the gallbladder. – Advantages include its ability to

assess function and positive results may appear before the ducts are enlarged sonographically.

• One disadvantage is that high bilirubin levels (>4.4) may decrease the sensitivity of the study.

Treatment• The initial treatment : intravenous antib

iotics and fluid resuscitation.• Patients with mild cholangitis, 80-90%

respond to medical therapy. • Approximately 15% do not respond and

subsequently require immediate surgical or endoscopic decompression.

• In severely ill patients, treatment is immediate biliary decompression.

Treatment• The selection of procedure should

be based on the level and the nat ure of the biliary obstruction.

• Patients with choledocholithiasis or periampullary malignancies ar

e best approached endoscopically , with sphincterotomy and stone r

emoval, or by placement of an en doscopic biliary stent.

Treatment• In patients in whom the obstructi

on is more proximal or perihilar, o - r stricture in a biliary enteric ana

stomosis is the cause or the endo scopic route has failed, percutane

ous transhepatic drainage is used .

Treatment• Where neither ERC nor PTC is pos

sible, an emergent operation and decompression of the common bil

e duct with a T tube may be neces - sary and life saving.

• Definitive operative therapy shou ld be deferred until the cholangiti

s has been treated and the proper diagnosis established.