Cholangitis differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Cholangitis}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Cholangitis]]
{{CMG}}; {{AE}} {{FH}}
{{CMG}}; {{AE}} {{ADS}} {{FH}}
==Overview==
==Overview==
Cholangitis must be differentiated from other causes of infection in the [[common bile duct]], as well as [[inflammation]] and infection of [[cholecystitis]].
Cholangitis must be differentiated from other causes of infection in the [[common bile duct]], as well as [[inflammation]] and infection of the gall bladder.and mainly from other causes of acute abdomen.


==Differentiating Cholangitis from other Diseases==
==Differentiating Cholangitis from other Diseases==
Line 17: Line 17:
*Gastic ulcer
*Gastic ulcer
*[[Pancreatic cancer]]
*[[Pancreatic cancer]]
===Differentiating acute cholangitis from other causes of acute abdomen===
==Differentiating acute cholangitis from other causes of abdominal pain==


{| class="wikitable"
 
! rowspan="2" |Acute/
The differential diagnosis of diseases presenting with abdominal pain, fever and jaundice are discussed below.
Chronic
 
! rowspan="2" |Disease
<span style="font-size:85%">'''Abbreviations:'''
! colspan="7" |Clinical findings
'''[[RUQ]]'''= Right upper quadrant of the abdomen, '''LUQ'''= Left upper quadrant, '''LLQ'''= Left lower quadrant, '''RLQ'''= Right lower quadrant, '''LFT'''= Liver function test, SIRS= [[Systemic inflammatory response syndrome]], '''[[ERCP]]'''= [[Endoscopic retrograde cholangiopancreatography]], '''IV'''= Intravenous, '''N'''= Normal, '''AMA'''= Anti mitochondrial antibodies, '''[[LDH]]'''= [[Lactate dehydrogenase]], '''GI'''= Gastrointestinal, '''CXR'''= Chest X ray, '''IgA'''= [[Immunoglobulin A]], '''IgG'''= [[Immunoglobulin G]], '''IgM'''= [[Immunoglobulin M]], '''CT'''= [[Computed tomography]], '''[[PMN]]'''= Polymorphonuclear cells, '''[[ESR]]'''= [[Erythrocyte sedimentation rate]], '''[[CRP]]'''= [[C-reactive protein]], TS= [[Transferrin saturation]], SF= Serum [[Ferritin]], SMA= [[Superior mesenteric artery]], SMV= [[Superior mesenteric vein]], ECG= [[Electrocardiogram]]</span>
! rowspan="2" |Causes
<small>
! colspan="2" |Laboratory findings
{| align="center"
!Treatment
|-
|-
!Fever
|
!Rigors and chills
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
!Abdominal pain
! colspan="3" rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Classification of pain in the abdomen based on etiology
!Site of pain
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Disease
!Jaundice
| colspan="13" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Clinical manifestations'''
!Hypotension
! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Diagnosis
!Other findings
! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Comments
!
!
!
|-
|-
| rowspan="12" |Acute
| colspan="9" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Symptoms'''
|'''Acute cholangitis /'''  
! colspan="4" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Signs
'''Ascending cholangits'''
|-
| +
! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain
|−
! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Fever
|<nowiki>+</nowiki>
! style="background:#4479BA; color: #FFFFFF;" align="center" |Rigors and chills
|RUQ
! style="background:#4479BA; color: #FFFFFF;" align="center" |Nausea or vomiting
| +
! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice
|
! style="background:#4479BA; color: #FFFFFF;" align="center" |Constipation
|
! style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea
* [[Nausea and vomiting]]
! style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss
|
! style="background:#4479BA; color: #FFFFFF;" align="center" |GI bleeding
* Gall stones
! style="background:#4479BA; color: #FFFFFF;" align="center" |Hypo-
|
tension
|
! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Guarding
|
! style="background:#4479BA; color: #FFFFFF;" align="center" |Rebound Tenderness
! style="background:#4479BA; color: #FFFFFF;" align="center" |Bowel sounds
! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Lab Findings
! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging
|-
! rowspan="16" style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal causes
! rowspan="15" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Inflammatory causes
! rowspan="6" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pancreato-biliary disorders
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Acute suppurative cholangitis
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*Abnormal [[LFT]]
*WBC >10,000
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ultrasound shows [[biliary]] dilatation/stents/tumor
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Septic shock occurs with features of [[SIRS]]
|-
|-
|'''Acute suppurative'''
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Cholangitis|Acute cholangitis]]
'''cholangitis'''
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[RUQ]]
| ++
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
|RUQ
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
* [[Confusion]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
* [[Nausea and vomiting]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
* Gall stones
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
|
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
|
* Abnormal [[LFT]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ultrasound shows [[biliary]] dilatation/stents/tumor
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Biliary drainage ([[Endoscopic retrograde cholangiopancreatography|ERCP]]) + IV antibiotics
|-
|-
|'''[[Acute cholecystitis]]'''
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Acute cholecystitis|Acute cholecystitis]]
|±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[RUQ]]
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|RUQ
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
* [[Nausea and vomiting]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
* Gall stones
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Hyperbilirubinemia]]
* [[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows:
* Gallstone
* Inflammation
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Murphy's sign|Murphy’s sign]]
|-
|-
|'''[[Acute pancreatitis]]'''
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |  [[Acute pancreatitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[Epigastric]]
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|LUQ, radiating to back
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
* [[Nausea and vomiting]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
* Gall stones
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Increased [[amylase]] / [[lipase]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ultrasound shows evidence of [[inflammation]]
* CT scan shows severity of pancreatitis
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Pain radiation to back
|-
|-
|'''[[Acute appendicitis]]'''
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Primary sclerosing cholangitis]]
|±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]]
| + in pyogenic/
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
perforated type
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
|Starts in umblical area and radiates to LLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
| + in perforated appendix
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Increased liver enzymes
* Increased [[IgM]], [[IgG]]4
* [[Anti-neutrophil cytoplasmic antibody]] ([[p-ANCA]])
* [[Anti-nuclear antibody]] ([[ANA]])
* [[Anti-smooth muscle antibody]] (Anti-Sm)
* Anti-endothelial antibody
* Anti-cardiolipin antibody
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |ERCP and MRCP shows
* Multiple segmental [[strictures]]
* Mural irregularities
* [[Biliary]] dilatation and diverticula
* Distortion of biliary tree
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* The risk of [[cholangiocarcinoma]] in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
|-
|-
|'''[[Acute hepatitis]]'''
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Cholelithiasis]]
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]]/[[Epigastric]]
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|[[RUQ]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal to hyperactive for dislodged stone
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ultrasound shows [[gallstone]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Fatty food intolerance
|-
|-
|'''[[Diverticulitis|Acute diverticulitis]]'''
! style="padding: 5px 5px; background: #DCDCDC;" align="center" |Gastric causes
| +
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Gastrointestinal perforation]]
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|LLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki>
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive/hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* WBC> 10,000
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Air under [[diaphragm]] in upright [[CXR]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Hamman's sign]]
|-
|-
|'''[[Peptic ulcer|Peptic Ulcer]]'''
! rowspan="3" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Intestinal causes
|±
! style="background:#4479BA; color: #FFFFFF;" align="center" |Disease
|
! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain
| +
! style="background:#4479BA; color: #FFFFFF;" align="center" |Fever
|[[Epigastrium]] or
! style="background:#4479BA; color: #FFFFFF;" align="center" |Rigors and chills
 
! style="background:#4479BA; color: #FFFFFF;" align="center" |Nausea or vomiting
[[RUQ]] (in duodenal ulcer)
! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice
|
! style="background:#4479BA; color: #FFFFFF;" align="center" |Constipation
|
! style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea
|
! style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss
|
! style="background:#4479BA; color: #FFFFFF;" align="center" |GI bleeding
|
! style="background:#4479BA; color: #FFFFFF;" align="center" |Hypo-
|
tension
|
! style="background:#4479BA; color: #FFFFFF;" align="center" |Guarding
! style="background:#4479BA; color: #FFFFFF;" align="center" |Rebound Tenderness
! style="background:#4479BA; color: #FFFFFF;" align="center" |Bowel sounds
! style="background:#4479BA; color: #FFFFFF;" align="center" |Lab Findings
! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging
! style="background:#4479BA; color: #FFFFFF;" align="center" |Comments
|-
|-
|'''[[Liver abscess]]'''
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Inflammatory bowel disease]]
| ++
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|RUQ
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal or hyperactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Anti-neutrophil cytoplasmic antibody]] ([[P-ANCA]]) in [[Ulcerative colitis]]
* [[Anti saccharomyces cerevisiae antibodies]] (ASCA) in [[Crohn's disease]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[String sign]] on [[abdominal x-ray]] in [[Crohn's disease]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
Extra intestinal findings:
* [[Uveitis]]
* [[Arthritis]]
|-
|-
|[[Choledocholithiasis|'''Choledocholithiasis''']]
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Whipple's disease]]
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|RUQ
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Thrombocytopenia]]
* [[Hypoalbuminemia]]
* [[Small intestinal]] [[biopsy]] for [[Tropheryma whipplei]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Whipple's disease other diagnostic studies|Endoscopy]] is used to confirm diagnosis.
Images used to find complications
*[[Whipple's disease x ray|Chest and joint x-ray]]
*[[Whipple's disease CT|CT]]
*[[Whipple's disease MRI|MRI]]
*[[Whipple's disease ultrasound|Echocardiography]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Extra intestinal findings:
* [[Uveitis]]
* [[Endocarditis]]
* [[Encephalitis]]
* [[Dementia]]
* [[Hepatosplenomegaly]]
* [[Arthritis]]
* [[Ascites]]
|-
|-
|'''Ruptured ovarian cyst / [[Ovarian torsion]]'''
! rowspan="4" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Hepatic causes
|±
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Hepatitis|Viral hepatitis]]
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]]
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|LLQ/ RLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Positive in Hep A and E
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Positive in fulminant hepatitis
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Positive in acute
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Abnormal LFTs
* Viral serology
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* US
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Hep A and E have fecal-oral route of transmission
* Hep B and C transmits via blood transfusion and sexual contact.
|-
|-
|'''[[Tubo-ovarian abscess]]'''
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Liver abscess]]
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|LLQ/ RLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|−
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal or hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* CBC
* Blood cultures
* Abnormal [[Liver function test|liver function tests]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* US
* CT
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
|-
|-
| rowspan="5" |Chronic
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Hepatocellular carcinoma]]/Metastasis
|'''[[Primary sclerosing cholangitis|Primary sclerosing]]'''
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ
'''[[Primary sclerosing cholangitis|cholangitis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Normal
* Hyperactive if obstruction present
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* High levels of [[Alpha-fetoprotein|AFP]] in serum
* Abnormal [[Liver function test|liver function tests]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* US
* CT
* Liver biopsy
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
Other symptoms:
* [[Splenomegaly]]
* [[Variceal bleeding]]
* [[Ascites]]
* [[Spider nevi]]
* [[Asterixis]]
|-
|-
|'''Primary biliary sclerosis'''
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Budd-Chiari syndrome|Budd-Chiari syndrome]]
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]]
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Positive in liver failure leading to varices
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*Elevated [[Aspartate aminotransferase|serum aspartate aminotransferase]] and [[alanine aminotransferase]] levels may be more than five times the upper limit of the normal range.
*Elevated serum [[alkaline phosphatase]] and [[Bilirubin|bilirubin levels]], decreased [[Albumin|serum albumin level]].
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|-
|-
|'''[[Chronic pancreatitis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Findings on [[CT scan]] suggestive of Budd-Chiari syndrome include:
|
*Early enhancement of the [[caudate lobe]] and [[central liver]] around the [[Inferior vena cavae|inferior vena cava]]
|
*Delayed enhancement of the peripheral [[liver]] with accompanying central low density (flip-flop appearance)
|
*Peripheral zones of the [[liver]] show reversed [[portal]] [[venous]] [[blood flow]]
|
*In the [[chronic]] phase, there is [[caudate lobe]] enlargement and [[atrophy]] of the [[Liver|peripheral liver]] in affected areas
|
|}
|
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Ascitic tap|Ascitic fluid examination]] shows:
|
*[[Total protein]] more than 2.5 g per deciliter
|
*[[White blood cells]] are usually less than 500/μL.
|
|
|
|-
|-
|'''[[Hepatitis]]'''
! rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Peritoneal causes
|
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Spontaneous bacterial peritonitis]]
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Positive in cirrhotic patients
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ascitic fluid [[PMN]]>250 cells/mm<small>³</small>
* Culture: Positive for single organism
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ultrasound for evaluation of liver cirrhosis
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
|-
|-
|'''Liver [[Cirrhosis]]'''
! colspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Hollow Viscous Obstruction
|
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Biliary colic]]
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
|
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* ↑ [[bilirubin]] and [[alkaline phosphatase]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ultrasound
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
|-
|-
| colspan="13" |RUQ= Right upper quadrant of the abdomen, LUQ= Left Upper quadrant, LLQ = Left lower quadrant, RLQ= Right lower quadrant
|}
|}
|}
</small>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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Latest revision as of 20:54, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2] Farwa Haideri [3]

Overview

Cholangitis must be differentiated from other causes of infection in the common bile duct, as well as inflammation and infection of the gall bladder.and mainly from other causes of acute abdomen.

Differentiating Cholangitis from other Diseases

Cholangitis should be differentiated from the following:[1]

Differentiating acute cholangitis from other causes of abdominal pain

The differential diagnosis of diseases presenting with abdominal pain, fever and jaundice are discussed below.

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute suppurative cholangitis RUQ + + + + + + + N
  • Abnormal LFT
  • WBC >10,000
  • Ultrasound shows biliary dilatation/stents/tumor
  • Septic shock occurs with features of SIRS
Acute cholangitis RUQ + + N
  • Ultrasound shows biliary dilatation/stents/tumor
  • Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis RUQ + + + Hypoactive Ultrasound shows:
  • Gallstone
  • Inflammation
Acute pancreatitis Epigastric + + ± + ± N
  • Ultrasound shows evidence of inflammation
  • CT scan shows severity of pancreatitis
  • Pain radiation to back
Primary sclerosing cholangitis RUQ + + N ERCP and MRCP shows
  • Multiple segmental strictures
  • Mural irregularities
  • Biliary dilatation and diverticula
  • Distortion of biliary tree
  • The risk of cholangiocarcinoma in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
Cholelithiasis RUQ/Epigastric ± ± ± Normal to hyperactive for dislodged stone
  • Fatty food intolerance
Gastric causes Gastrointestinal perforation Diffuse + ± - ± + + + ± Hyperactive/hypoactive
  • WBC> 10,000
Intestinal causes Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Inflammatory bowel disease Diffuse ± ± + + + Normal or hyperactive

Extra intestinal findings:

Whipple's disease Diffuse ± ± + + ± N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Hepatic causes Viral hepatitis RUQ + + + Positive in Hep A and E + Positive in fulminant hepatitis Positive in acute + N
  • Abnormal LFTs
  • Viral serology
  • US
  • Hep A and E have fecal-oral route of transmission
  • Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + + ± + + + ± Normal or hypoactive
  • US
  • CT
Hepatocellular carcinoma/Metastasis RUQ + + +
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy

Other symptoms:

Budd-Chiari syndrome RUQ ± ± Positive in liver failure leading to varices N
Findings on CT scan suggestive of Budd-Chiari syndrome include:
Ascitic fluid examination shows:
Peritoneal causes Spontaneous bacterial peritonitis Diffuse + Positive in cirrhotic patients + ± + + Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
  • Ultrasound for evaluation of liver cirrhosis
Hollow Viscous Obstruction Biliary colic RUQ + + N
  • Ultrasound

References

  1. Miura F, Takada T, Kawarada Y, Nimura Y, Wada K, Hirota M, Nagino M, Tsuyuguchi T, Mayumi T, Yoshida M, Strasberg SM, Pitt HA, Belghiti J, de Santibanes E, Gadacz TR, Gouma DJ, Fan ST, Chen MF, Padbury RT, Bornman PC, Kim SW, Liau KH, Belli G, Dervenis C (2007). "Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg. 14 (1): 27–34. doi:10.1007/s00534-006-1153-x. PMC 2784508. PMID 17252294.


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