Ascending cholangitis

Question 1

What is Charcot’s triad?

Answer 1

• Fever
• RUQ pain
• Jaundice

Question 2

What is Reynold’s pentad?

Answer 2

-Charcot’s triad
-Hypotension
-Altered mental status
Indicates cholangitis + sepsis due to reflux of bacteria from increased intraductal pressure.

Question 3

What is ascending cholangitis?

Answer 3

Infection of the biliary tree

Question 4

Aetiology of ascending cholangitis?

Answer 4

• Stasis of biliary tract due to obstruction or stricture (usually previous cholecystectomy)
• Infection originates in duodenum or spreads haematogenously from portal vein

Question 5

Common bacteria causing ascending cholangitis?

Answer 5

-E. coli
-Klebsiella
-Enterobacter
-Enterococcus
May have coinfection with Bacteroides and Clostridia

Question 6

Signs/ symptoms in suppurative cholangitis?

Answer 6

Reynold’s pentad

Question 7

Diagnosis of ascending cholangitis?

Answer 7

• Increased WBC
• Increased ALP and bilirubin
• ALT variably elevated
• Blood culture
• Abdo U/S: CBD dilation, stones

Question 8

Treatment of ascending cholangitis?

Answer 8

ABx and ICU medical Mx

• Drainage (preferably ERCP)
• ABx (broad spectrum) e.g. piperacillin / tazobactam, metronidazole and ceftriaxone, or carbapenem monotherapy.
• Opioid analgesia

Question 9

DDx ascending cholangitis?

Answer 9

• Acute cholecystitis (will be Murphy’s +ve)
• PUD (food/antacid improves)
• Acute pancreatitis

Question 10

Ix in ascending cholangitis?

Answer 10

• FBE
• UEC
• ABGs
• LFTs
• CRP
• Blood cultures
• ERCP

Question 11

ABG results in severe cholangitis?

Answer 11

Severe cases = low bicarb with raised anion gap metabolic acidosis

Question 12

What needs to be covered by cholangitis ABx therapy?

Answer 12

• Enterococci
• G-ve bacilli
  e. g. ampicillin + gentamicin +/- metronidazole OR tazobactam + piperacillin