Ascending cholangitis

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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

Causes

  • Choledocholithiasis
  • Biliary tract stricture
  • 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

Differential Diagnosis

RUQ Pain

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)

  • 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

References