Ascending cholangitis: Difference between revisions
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{{Gallbladder background}} | {{Gallbladder background}} | ||
{{Gallbladder disease types}} | |||
===Causes=== | ===Causes=== | ||
*Choledocholithiasis | *[[Choledocholithiasis]] | ||
*Biliary tract stricture | *Biliary tract stricture | ||
*Compression by malignant disease | *Compression by malignant disease | ||
Line 12: | Line 14: | ||
*Charcot's Triad: [[Fever]] + [[jaundice]] + [[RUQ pain]] | *Charcot's Triad: [[Fever]] + [[jaundice]] + [[RUQ pain]] | ||
**Occurs in ~50% | **Occurs in ~50% | ||
*Reynold's Pentad: The triad + [[ | *Reynold's Pentad: The triad + [[altered mental status]] + [[hypotension]] | ||
**Occurs in <5% | **Occurs in <5% | ||
**Hypotension may be the only presenting sign in elderly patients | **[[Hypotension]] may be the only presenting sign in elderly patients | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{DDX RUQ}} | {{DDX RUQ}} | ||
== | ==Evaluation== | ||
[[File:CBD stones.jpg|thumb|MRCP image of two stones in the distal common bile duct]] | |||
===Work-up=== | |||
*Labs | *Labs | ||
**Leukocytosis with neutrophil predominance | **CBC: [[Leukocytosis]] with neutrophil predominance | ||
**Elevated alk phos | **[[LFTs]]: Elevated alk phos and conjugated bilirubin | ||
**Blood | **GGT elevation much more sensitive than alk phos | ||
**Blood cultures | |||
*Imaging | *Imaging | ||
**[[ | **[[Biliary ultrasound|RUQ Ultrasound]] | ||
***Dilatation of CBD ( > 6mm) and presence of choledocholithiasis | ***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 | ***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 | *Aggressive [[sepsis]] resuscitation | ||
== | ===Antibiotics=== | ||
{{Cholangitis antibiotics}} | |||
===Consultation=== | |||
*Involvement with GI for ERCP and general surgery for acute cholecystectomy is necessary for source control and biliary decompression | |||
==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 19:47, 29 September 2019
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.
Gallbladder disease types
- Symptomatic cholelithiasis (biliary colic)
- Choledocholithiasis
- Acute calculous cholecystitis
- Ascending cholangitis
- Acalculous cholecystitis
- Biliary atresia
- Cholestasis of pregnancy
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
- 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
Evaluation
Work-up
- Labs
- CBC: Leukocytosis with neutrophil predominance
- LFTs: Elevated alk phos and conjugated bilirubin
- GGT elevation much more sensitive than alk phos
- 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 sepsis resuscitation
Antibiotics
Coverage is targeted at E. coli, Enterococcus, Bacteroides, and Clostridium (anerobic)
- Metronidazole 500mg IV q8hrs PLUS Ciprofloxacin 400mg IV q12hrs
- Piperacillin/Tazobactam 4.5g IV q8hrs
- Imipenem/Cilastin 500mg IV q6hrs
- Doripenem 500mg IV q8hrs
- Meropenem 1g IV q8hrs
- expand coverage for MRSA if severe sepsis or septic shock
- Vancomycin 15-20mg/kg PLUS any of the following options
Consultation
- Involvement with GI for ERCP and general surgery for acute cholecystectomy is necessary for source control and biliary decompression
Disposition
- Admit