Cholangitis: Difference between revisions

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==Treatment==
==Treatment==
[[Cholangitis medical therapy|Medical therapy]] | [[Cholangitis surgery|Surgical options]] | [[Cholangitis primary prevention|Primary prevention]]  | [[Cholangitis secondary prevention|Secondary prevention]] | [[Cholangitis cost-effectiveness of therapy|Financial costs]] | [[Cholangitis future or investigational therapies|Future therapies]]
[[Cholangitis medical therapy|Medical therapy]] | [[Cholangitis surgery|Surgical options]] | [[Cholangitis primary prevention|Primary prevention]]  | [[Cholangitis secondary prevention|Secondary prevention]] | [[Cholangitis cost-effectiveness of therapy|Financial costs]] | [[Cholangitis future or investigational therapies|Future therapies]]
== Pathophysiology ==
The presence of [[gallstones]] alone predisposes to bacterial colonization.  70% of patients with gallstones will have bacteria in the bile while normal bile is usually sterile.  CBD have a higher probability of infection.  80% of stones can be culture positive.
The source of biliary infection is usually ascending from the [[duodenum]] or [[jejunum]] and less commonly direct hematogenous seeding of the [[Portal venous system|portal system]].  In the presence of obstruction, the small [[bowel]] becomes colonized with colonic flora.  The common organisms are [[E.coli]], [[Klebsiella]], [[Enterococcus]], [[Enterobacter]], [[Proteus]].  [[Anaerobic organism|Anaerobes]] ([[Strep]], [[Bacteroides]], [[Clostridia]]) can be found particularly in the elderly.  Higher incidence of [[Pseudomonas]] in those who have been instrumented.  Broad spectrum antibiotics to cover [[Gram-negative bacteria|Gram negatives]] including [[Pseudomonas]], Enterococcus  and anaerobes are needed up front.  [[Cephalosporins]] should not be used as [[monotherapy]].  [[Cipro]] has been shown in one study to be as effective as monotherapy despite poor coverage for anaerobes and EC.
The most common causes of biliary obstruction are [[Gallstone|biliary calculi]], benign stricture or malignant [[neoplasms]].  Benign strictures are caused by primary [[Sclerotherapy|sclerosing]] cholangitis, [[ischemic]] cholangitis, [[iatrogenic]] [[biliary tract]] injury, [[congenital disease]] and [[infection]].  Chronic inflammation predisposed to the development of cholangiocarcinoma.  Extraluminal obstruction can occur from [[pancreatic cancer]] or [[pseudocyst]], [[lymphoma]], [[hepatoma]], [[metastatic]] disease or ampullary cancer.
Biliary obstruction leads to elevated biliary pressures, favoring migration of bacteria into the portal circulation and bile.  As pressures increase [[hepatocyte]] secretion is impaired and bacteria move into the [[lymphatics]] and [[systemic circulation]].


== Diagnosis ==
== Diagnosis ==

Revision as of 16:15, 27 January 2012

Cholangitis
Recurrent pyogenic cholangitis.
(Image courtesy of RadsWiki)
ICD-10 K83.0
ICD-9 576.1
DiseasesDB 2514
eMedicine med/2665  emerg/96
MeSH D002761

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Historical Perspective

Pathophysiology

Epidemiology & Demographics

Risk Factors

Screening

Causes

Differentiating Cholangitis

Complications & Prognosis

Diagnosis

History and Symptoms | Physical Examination | Staging | Laboratory tests | Electrocardiogram | X Rays | CT | MRI Echocardiography or Ultrasound | Other images | Alternative diagnostics

Treatment

Medical therapy | Surgical options | Primary prevention | Secondary prevention | Financial costs | Future therapies

Diagnosis

50-60% of patients will have all three of Charcot’s triad. 95% will have fever, 66% abdominal pain, jaundice is noted in 80% (When bilirubin >2.5). Nonobstructive stones are more likely to present without pain or fever. Elderly patients may present only with hypotension. Dark urine is noted and acholia can be seen.

The combination of hyperbilirubinemia, elevated white blood cell (WBC) count with bandemia, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase elevations all suggest the diagnosis. Alkaline phosphatase and bilirubin are significantly higher inpatients with malignant rather than benign obstruction. In benign obstruction, the bilirubin rarely exceeds 12. Gamma-glutamyltransferase (GGT) and 5’-nucleotidase confirm a biliary origin of the alkaline phosphatase. The prothrombin time is often elevated. AST and ALT may be as high as 1000, especially if microabcesses form.

MRI and CT

CT has a higher sensitivity (63%) and is better to localize the site of obstruction.

MRI

(Images courtesy of RadsWiki)

Other Imaging Findings

  • Ultrasound: Diagnostic evaluation should proceed first with ultrasound which has an 55-85% sensitivity. Small stones in the common bile duct may be missed. The CBD may not be enlarged early or if the stones has passed. The ducts may be totally normal in PSC.

Treatment

80% of patients with acute cholangitis will respond to conservative therapy and elective drainage. In 15-20%, the cholangitis will progress requiring emergent drainage. Markers for these people are persistent abdominal pain, hypotensive, fever >102, and confusion.

Patients should be kept NPO, given IVF, broad spectrum ABX, Vitamin K and be drained. Choices for drainage are ERCP with stone removal and sphincterotomy/stent placement, surgically drainage or percutaneous drainage. Intrahepatic stones cannot be removed via ERCP and should be drained percutaneously. Randomized trials comparing ERCP and surgery showed morbidity and mortality benefit for ERCP (4.7-10% versus 10-50%). A nasobiliary catheter can be placed if ERCP is impossible (<5%) either because of coagulopathy precluding sphincterotomy, too large a stone (>2cm) etc. Next step should be percutaneous drainage as a bridge to elective surgery since emergent surgery has an up to 40% mortality.

References

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