Ascending cholangitis

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
  • 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

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
• ERCP
  • Should be obtained to confirm the diagnosis and to intervene

Management

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

See Also

• Gallbladder Disease (Main)