Ascending cholangitis: Difference between revisions
| Line 31: | Line 31: | ||
==Management== | ==Management== | ||
*Aggressive volume replacement | *Aggressive volume replacement | ||
*Broad-spectrum parenteral [[ | *Broad-spectrum parenteral [[antibiotics]] covering [[gram negatives]], [[gram positives]], and [[anerobes]] | ||
**[[Piperacillin/tazobactam]] OR [[ampicillin-sulbactam]] OR ([[ceftriaxone]] + [[metronidazole]]) | **[[Piperacillin/tazobactam]] OR [[ampicillin-sulbactam]] OR ([[ceftriaxone]] + [[metronidazole]]) | ||
*Emergent ERCP | *Emergent ERCP | ||
Revision as of 04:52, 21 May 2015
Background
- Also known as "ascending cholangitis"
- Requires the presence of biliary obstruction and infected biliary tract
- Causes:
- Choledocholithiasis
- Biliary tract stricture
- Compression by malignant disease
Clinical Features
- Charcot's Triad: Fever + jaundice + RUQ pain
- Occurs in ~50%
- Reynold's Pentad: The triad + AMS + hypotension
- Occurs in <5%
- Hypotension may be the only presenting sign in elderly patients
Differential Diagnosis
RUQ Pain
- Gallbladder disease
- Pancreatitis
- Acute hepatitis
- Pancreatitis
- GERD
- Appendicitis (retrocecal)
- Pyogenic liver abscess
- Bowel obstruction
- Cirrhosis
- Budd-Chiari syndrome
- GU
- Other
- Hepatomegaly due to CHF
- Peptic ulcer disease with or without perforation
- Pneumonia
- Herpes zoster
- Myocardial ischemia
- Pulmonary embolism
- Abdominal aortic aneurysm
Diagnosis
- Labs
- Leukocytosis with neutrophil predominance
- Elevated alk phos, conj. bilirubin
- Blood culture is indicated
- 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
- RUQ Ultrasound
- ERCP
- Should be obtained to confirm the diagnosis and to intervene
Management
- Aggressive volume replacement
- Broad-spectrum parenteral antibiotics covering gram negatives, gram positives, and anerobes
- Emergent ERCP