Ascending cholangitis: Difference between revisions
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{{Gallbladder background}} | {{Gallbladder background}} | ||
[[File:CBD stones.jpg|thumb|MRCP image of two stones in the distal common bile duct]] | |||
===Causes=== | ===Causes=== | ||
*Choledocholithiasis | *Choledocholithiasis | ||
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==Diagnosis== | ==Diagnosis== | ||
===Work-up=== | |||
*Labs | *Labs | ||
**Leukocytosis with neutrophil predominance | **Leukocytosis with neutrophil predominance | ||
**Elevated alk phos | **Elevated alk phos and conjugated bilirubin | ||
**Blood | **Blood cultures | ||
*Imaging | *Imaging | ||
**[[Ultrasound: Gallbladder|RUQ Ultrasound]] | **[[Ultrasound: Gallbladder|RUQ Ultrasound]] | ||
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***May miss small CBD stones and in acute cases CBD may not have had time to dilate | ***May miss small CBD stones and in acute cases CBD may not have had time to dilate | ||
*ERCP | *ERCP | ||
**Should be obtained to confirm the diagnosis and for possible intervention | |||
**Should be obtained to confirm the diagnosis and | |||
==Management== | ==Management== | ||
*Aggressive volume replacement | *Aggressive volume replacement | ||
*Broad-spectrum parenteral [[antibiotics]] covering [[gram negatives]], [[gram positives]], and [[anerobes]] | *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 | ||
== | ==Disposition== | ||
*Admit | |||
==See Also== | ==See Also== | ||
*[[Gallbladder Disease (Main)]] | *[[Gallbladder Disease (Main)]] | ||
==References== | |||
<References/> | |||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:ID]] | [[Category:ID]] | ||
Revision as of 07:15, 18 August 2015
Background
- Also known as "ascending cholangitis"
- Requires the presence of biliary obstruction and infected biliary tract
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.
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
Work-up
- Labs
- Leukocytosis with neutrophil predominance
- Elevated alk phos and conjugated bilirubin
- 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
- RUQ Ultrasound
- ERCP
- Should be obtained to confirm the diagnosis and for possible intervention
Management
- Aggressive volume replacement
- Broad-spectrum parenteral antibiotics covering gram negatives, gram positives, and anerobes
- Emergent ERCP
Disposition
- Admit