Ascending cholangitis

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.

MRCP image of two stones in the distal common bile duct

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 + altered mental status + hypotension
  • Occurs in <5%
  • Hypotension may be the only presenting sign in elderly patients

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

Evaluation

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
• 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
  • Piperacillin/tazobactam OR ampicillin-sulbactam OR (ceftriaxone + metronidazole)
• Emergent ERCP

Disposition

• Admit

See Also

• Gallbladder Disease (Main)