Cholangitis

Background

  • Also known as "ascending cholangitis"
  • Requires the presence of biliary obstruction and infected biliary tract

Anatomy & Pathophysiology

Gallbladder anatomy
  • 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

Causes

  • Choledocholithiasis
  • Biliary tract stricture
  • Compression by malignant disease

Clinical Features

Differential Diagnosis

RUQ Pain

Evaluation

MRCP image of two stones in the distal common bile duct

Work-up

  • Labs
    • Leukocytosis with neutrophil predominance
    • 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
  • 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)

  • 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

See Also

References