Ascending cholangitis

Background

• Requires the presence of biliary obstruction and infected biliary tract
• Causes:
  • Choledocholithiasis
  • Biliary tract stricture
  • Compression by malignant disease

Diagnosis

1. Charcot's Triad: Fever + jaundice + RUQ pain
   1. Occurs in ~50%
2. Reynold's Pentad: The triad + AMS + hypotension
   1. Occurs in <5%
   2. Hypotension may be the only presenting sign in elderly pts
3. Labs
   1. Leukocytosis with neutrophil predominance
   2. Elevated alk phos, conj. bilirubin
   3. Blood culture is indicated
4. Imaging
   1. RUQ Ultrasound
      1. Dilatation of CBD ( > 6mm) and presence of choledocholithiasis
      2. May miss small CBD stones and in acute cases CBD may not have had time to dilate
5. ERCP
   1. Should be obtained to confirm the diagnosis and to intervene

Differential Diagnosis

RUQ Pain

• Gallbladder disease
  • Symptomatic cholelithiasis (biliary colic)
  • Choledocholithiasis
  • Acute cholecystitis
  • Ascending cholangitis
  • Acalculous cholecystitis
• Pancreatitis
• Acute hepatitis
• Pancreatitis
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Bowel obstruction
• Cirrhosis
• Budd-Chiari syndrome
• GU
  • Pyelonephritis
  • Kidney stone
  • Fitz-Hugh-Curtis Syndrome
• Other
  • Hepatomegaly due to CHF
  • Peptic ulcer disease with or without perforation
  • Pneumonia
  • Herpes zoster
  • Myocardial ischemia
  • Pulmonary embolism
  • Abdominal aortic aneurysm

Management

1. Aggressive volume replacement
2. Broad-spectrum parenteral abx covering gram neg, gram pos, and anerobes
   1. Piperacillin/tazobactam OR ampicillin-sulbactam OR (ceftriaxone + metronidazole)
3. Emergent ERCP

Source

• UpToDate
• Tintinalli

See Also

Gallbladder Disease (Main)