Acute Cholangitis
Pathogenesis
• obstruction of CBD → biliary stasis, bacterial overgrowth, suppuration and biliary sepsis – may be life-threatening, especially in elderly
Etiology
• choledocholithiasis (60%), stricture, neoplasm (pancreatic or biliary), extrinsic compression (pancreatic pseudocyst or pancreatitis), instrumentation of bile ducts (PTC, ERCP), biliary stent
• organisms: E. coli, Klebsiella, Pseudomonas, Enterococcus, B. fragilis, Proteus
Clinical Features
• Charcot's triad: fever, RUQ pain, jaundice
• Reynold’s pentad: fever, RUQ pain, jaundice, shock, confusion
• may have nausea, vomiting, abdominal distention, ileus, acholic stools, tea-coloured urine
(elevated direct bilirubin)
Investigations
• CBC: elevated WBC + left shift
• may have positive blood cultures
• LFTs: obstructive picture (elevated ALP, GGT and conjugated bilirubin, mild increase in AST, ALT)
• amylase/lipase: rule out pancreatitis
• U/S: intra/extra-hepatic duct dilatation
Treatment
• initial: NPO, fluid and electrolyte resuscitation, ± NG tube, IV antibiotics (treats 80%)
• decompression:
ERCP + sphincterotomy: diagnostic and therapeutic
PTC with catheter drainage: if ERCP not available or unsuccessful
laparotomy with CBD exploration and T-tube placement if above fails
all patients should also have a cholecystectomy, unless contraindicated
Prognosis
• suppurative cholangitis mortality rate: 50%